Provider Demographics
NPI:1033328497
Name:HARRISON, JESSICA FAYE (RN,)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:FAYE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:RN,
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:FAYE
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DVM
Mailing Address - Street 1:1805 DONNER AVE
Mailing Address - Street 2:#1
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-0366
Mailing Address - Country:US
Mailing Address - Phone:530-753-0311
Mailing Address - Fax:
Practice Address - Street 1:1805 DONNER AVE
Practice Address - Street 2:#1
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-0366
Practice Address - Country:US
Practice Address - Phone:530-753-0311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2008-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA453798163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
EPS #007060OtherMEDI-CAL EPSDT
RVN#004810OtherMEDI-CAL HCBS