MEDICARE: MS. JENNIFER LARSON M.A., LCPC, NCC

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	180006534	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01638687	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1508041807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER LARSON M.A., LCPC, NCC

Provider Business Mailing Address
First Line	:	5142 N LEAVITT ST
Second Line	:	STE 2
City	:	CHICAGO
State	:	IL
Zip	:	60625-6829
Country	:	US
Telephone Number	:	773-398-0359
Fax Number	:	773-989-7207

Provider Business Practice Location Address
First Line	:	25 E WASHINGTON ST STE 1406
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60602-1820
Country	:	US
Telephone Number	:	773-398-0359
Fax Number	:	773-989-7207

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

Provider Enumeration Date	:	01/04/2008
Last Update Date	:	08/07/2013

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