MEDICARE: JENNIFER LARSON RPH

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	RPH43955	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RPH43955	OTHER	CA	BOARD OF PHARMACY CALIFORNIA

General Provider Information

NPI Number	:	1972975019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LARSON RPH

Provider Business Mailing Address
First Line	:	2707 GALLOP DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95407-4541
Country	:	US
Telephone Number	:	415-734-8321
Fax Number	:

Provider Business Practice Location Address
First Line	:	2707 GALLOP DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95407-4541
Country	:	US
Telephone Number	:	415-734-8321
Fax Number	:

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

Provider Enumeration Date	:	10/28/2015
Last Update Date	:	10/28/2015

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