Individual
JACK LARSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
917 W WALNUT ST, JOHNSON CITY, TN 37604
(423) 439-6464
Mailing address
PO BOX 699, MOUNTAIN HOME, TN 37684-0699
(423) 433-6050
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
63135
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
Q050572
—
TN
Enumeration date
03/21/2019
Last updated
01/18/2024
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