Provider Demographics
NPI:1174056154
Name:LARSON, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 S 25TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1364
Mailing Address - Country:US
Mailing Address - Phone:906-233-1848
Mailing Address - Fax:906-233-9310
Practice Address - Street 1:128 S 25TH ST STE B
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1364
Practice Address - Country:US
Practice Address - Phone:906-233-1848
Practice Address - Fax:906-233-9310
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010902251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical