Provider Demographics
NPI:1043687700
Name:CAMMON-LARSON, JENNIFER PATRICIA (PLMHP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PATRICIA
Last Name:CAMMON-LARSON
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 BAUMANN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4401
Mailing Address - Country:US
Mailing Address - Phone:308-385-5250
Mailing Address - Fax:308-385-5271
Practice Address - Street 1:914 BAUMANN DR
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4401
Practice Address - Country:US
Practice Address - Phone:308-385-5250
Practice Address - Fax:308-385-5271
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10649101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health