Provider Demographics
NPI:1174612253
Name:LARSON, JILL C (DO)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:LARSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:N17 W24100 RIVERWOOD DR.
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES, INC.
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1177
Mailing Address - Country:US
Mailing Address - Phone:262-928-4100
Mailing Address - Fax:262-928-5835
Practice Address - Street 1:240 MAPLE AVE.
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES, INC.
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-8475
Practice Address - Country:US
Practice Address - Phone:262-928-1900
Practice Address - Fax:262-928-1949
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI49669-021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI683750635Medicare PIN
WI68605Medicare ID - Type Unspecified