MEDICARE: JESSICA LARKIN

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	225100000X	Physical Therapist		CA

General Provider Information

NPI Number	:	1972933430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LARKIN

Provider Business Mailing Address
First Line	:	17248 SANTA LUCIA ST
Second Line	:
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-3116
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	24422 AVENIDA DE LA CARLOTA STE 100
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-3648
Country	:	US
Telephone Number	:	949-916-1654
Fax Number	:

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

Provider Enumeration Date	:	11/20/2013
Last Update Date	:	11/20/2013

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