Provider Demographics
NPI:1487606679
Name:LARSON, JOHN JEFFREY (LAT, ATC,CSCS)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JEFFREY
Last Name:LARSON
Suffix:
Gender:M
Credentials:LAT, ATC,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W FRANSEE LN
Mailing Address - Street 2:
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080-1714
Mailing Address - Country:US
Mailing Address - Phone:262-268-9869
Mailing Address - Fax:
Practice Address - Street 1:6701 N JEAN NICOLET RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-3701
Practice Address - Country:US
Practice Address - Phone:414-351-8154
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI205-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer