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General NPI Number Information
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NPI Number | 1932360906
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Entity Type | Individual
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Provider Name | JENNIFER LYNN LARUSSO D.O.
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Gender | Female
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Dates
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Enumeration Date | 06/22/2008
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Last Update Date | 07/14/2014
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Provider Practice Location Address
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Address Line | 771 E ROUTE 70 SUITE D150
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City | MARLTON
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State | NJ
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Zip | 08053-2352
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Country | US
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Telephone | 856-569-3393
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Fax | 856-596-3394
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Provider Business Mailing Address
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Address Line | 34 CROWS NEST CT
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City | MOUNT LAUREL
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State | NJ
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Zip | 08054-6109
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Country | US
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Telephone | 856-273-5811
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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 | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | OS013778
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | OS013778
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 25MB07507100
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License Number State | NJ
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