Basic Information
| Provider Information | |||||||||
| NPI: | 1578995825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N 34TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548804477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153928216 | ||||||||
| FaxNumber: | 7153926055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 N 34TH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548804477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153928216 | ||||||||
| FaxNumber: | 7153926055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2013 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3747P1801X | N | Nursing Service Related Providers | Technician | Personal Care Attendant | 1041C0700X | 130527 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 25873 | MN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.