MEDICARE: MS. JENNIFER LARSON

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	101YP2500X	Professional Counselor	74786	TX

General Provider Information

NPI Number	:	1245992841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER LARSON

Provider Business Mailing Address
First Line	:	736 SAINT ANDREWS LN
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-8234
Country	:	US
Telephone Number	:	817-715-7076
Fax Number	:

Provider Business Practice Location Address
First Line	:	8515 GREENVILLE AVE STE N-206
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-7011
Country	:	US
Telephone Number	:	214-221-0855
Fax Number	:

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

Provider Enumeration Date	:	10/11/2021
Last Update Date	:	06/02/2022

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