Individual
JAKE WESSLEY LARSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1820 PITT ST NE, ALBUQUERQUE, NM 87112-3122
(916) 634-3773
Mailing address
1201 3RD ST NW, ALBUQUERQUE, NM 87102-1403
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1902918055
—
NM
Enumeration date
08/15/2022
Last updated
08/15/2022
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