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NPI Code Detail

MEDICARE: JEREMY SCOTT LARSEN

MEDICARE: JEREMY SCOTT LARSEN
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
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1780453647
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEREMY SCOTT LARSEN
Provider Business Mailing Address
First Line : 8072 S HIGHLAND DR
Second Line :
City : COTTONWOOD HEIGHTS
State : UT
Zip : 84121-5037
Country : US
Telephone Number : 385-351-5483
Fax Number :
Provider Business Practice Location Address
First Line : 8072 S HIGHLAND DR
Second Line :
City : COTTONWOOD HEIGHTS
State : UT
Zip : 84121-5037
Country : US
Telephone Number : 385-351-5483
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/20/2023
Last Update Date : 12/20/2023

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