Provider Demographics
NPI:1679199350
Name:LARSON, JESSICA LYNN (MA, LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:LARSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11358 VAN CLEVE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-1131
Mailing Address - Country:US
Mailing Address - Phone:314-968-2350
Mailing Address - Fax:
Practice Address - Street 1:11358 VAN CLEVE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-1131
Practice Address - Country:US
Practice Address - Phone:314-968-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020009173101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional