MEDICARE: JENNA LYNN LARROW BA, IS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1073183406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA LYNN LARROW BA, IS

Provider Business Mailing Address
First Line	:	5890 BRIGHTON AVE
Second Line	:
City	:	GARDEN CITY
State	:	ID
Zip	:	83714-1235
Country	:	US
Telephone Number	:	208-841-1127
Fax Number	:

Provider Business Practice Location Address
First Line	:	5890 BRIGHTON AVE
Second Line	:
City	:	GARDEN CITY
State	:	ID
Zip	:	83714-1235
Country	:	US
Telephone Number	:	208-841-1127
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2021
Last Update Date	:	07/06/2021

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