MEDICARE: JESSICA LARSON OD

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	152W00000X	Optometrist	2828	AR

General Provider Information

NPI Number	:	1467022590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LARSON OD

Provider Business Mailing Address
First Line	:	389 ROCK ST APT 105
Second Line	:
City	:	TONTITOWN
State	:	AR
Zip	:	72762-4395
Country	:	US
Telephone Number	:	501-762-7910
Fax Number	:

Provider Business Practice Location Address
First Line	:	4189 PHOENIX AVE STE B
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-6013
Country	:	US
Telephone Number	:	479-434-4668
Fax Number	:

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

Provider Enumeration Date	:	06/30/2021
Last Update Date	:	06/30/2021

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