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General NPI Number Information
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NPI Number | 1215758172
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Entity Type | Individual
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Provider Name | JENNA LYNN LARSON
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Gender | Female
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Dates
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Enumeration Date | 10/22/2024
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Last Update Date | 10/26/2024
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Provider Practice Location Address
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Address Line | 1517 HIGHWAY 13 E
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City | BURNSVILLE
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State | MN
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Zip | 55337-2917
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Country | US
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Telephone | 612-237-1750
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Fax |
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Provider Business Mailing Address
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Address Line | 7211 CREEKWOOD LN
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City | PRIOR LAKE
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State | MN
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Zip | 55372-2211
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Country | US
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Telephone | 612-685-0204
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 307046
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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