Jack Larsen

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

63135 Issued in TN

Practice address

917 W Walnut St
Johnson City, TN 37604

Phone

(423) 439-6464

NPI assigned

Mar 21, 2019

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in TN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Family Practice

Education

Other, 2019

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Medical Education Assistance CorporationGroup PAC ID 3870491269, 168 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Medical Education Assistance Corporation

  • Internal Medicine Physician
  • Johnson City, TN
  • NPI 1235180480

  Family Medicine

  Medicare reassignment Care Compare group NPD
• Medical Education Assistance Corporation

  • Family Medicine Physician
  • Kingsport, TN
  • NPI 1588786768
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1553126400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1705536000000",
    "number": "1972063444",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 699",
            "city": "MOUNTAIN HOME",
            "state": "TN",
            "postal_code": "376840699",
            "telephone_number": "423-433-6050"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "917 W WALNUT ST",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "37604",
            "telephone_number": "423-439-6464"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "208 Medical Park Blvd",
            "address_purpose": "LOCATION",
            "city": "Bristol",
            "state": "TN",
            "postal_code": "37620",
            "country_code": "US",
            "telephone_number": "423-989-4050",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "102 E Ravine Rd",
            "address_purpose": "LOCATION",
            "city": "Kingsport",
            "state": "TN",
            "postal_code": "376603814",
            "country_code": "US",
            "telephone_number": "423-245-9600",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "100 Newell Drive",
            "address_purpose": "LOCATION",
            "city": "Gainesville",
            "state": "FL",
            "postal_code": "326103814",
            "country_code": "US",
            "telephone_number": "352-265-4357",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "LARSEN",
        "first_name": "JACK",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-03-21",
        "last_updated": "2024-01-18",
        "certification_date": "2024-01-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TN",
            "license": "63135",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q050572",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sheila Lapomarede
• Katie Potter Larkey
• Donald Wayne Larkin, PHD
• Megan Larose, DPT
• Brian Patrick Larsen Wells
• Margaret A Lassiter, PHARMD
• Daniel Latham, LPC/MHSP
• Tido A Latour, CRNA
• Latrobe Dialysis LLC
• Whitney Charlena Lau, MS, CCC-SLP

• Family Medicine Physician in Johnson City, TN
• Providers in Johnson City, TN by specialty
• Family Medicine Physician in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.