Provider Demographics
NPI:1205193125
Name:HARRIS, JACALYN D (RPT)
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:D
Last Name:HARRIS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2737 FOREST AVE
Mailing Address - Street 2:APT. 202
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1360
Mailing Address - Country:US
Mailing Address - Phone:510-848-3974
Mailing Address - Fax:
Practice Address - Street 1:2737 FOREST AVE
Practice Address - Street 2:APT. 202
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1360
Practice Address - Country:US
Practice Address - Phone:510-848-3974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT84492251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology