Provider Demographics
NPI:1376351973
Name:JARDINE, LARISSA K
Entity type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:K
Last Name:JARDINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:BRADSHAW
Mailing Address - State:NE
Mailing Address - Zip Code:68319-0103
Mailing Address - Country:US
Mailing Address - Phone:402-580-1098
Mailing Address - Fax:
Practice Address - Street 1:400 CLARK ST
Practice Address - Street 2:
Practice Address - City:BRADSHAW
Practice Address - State:NE
Practice Address - Zip Code:68319-3024
Practice Address - Country:US
Practice Address - Phone:402-580-1098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant