Provider Demographics
NPI:1235602822
Name:HARRIS, JESSICA DAWN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:HARRIS
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 1:5885 S BOB WHITE DR
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:MI
Mailing Address - Zip Code:48074-4619
Mailing Address - Country:US
Mailing Address - Phone:810-919-7251
Mailing Address - Fax:
Practice Address - Street 1:5885 S BOB WHITE DR
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:MI
Practice Address - Zip Code:48074-4619
Practice Address - Country:US
Practice Address - Phone:810-919-7251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010987121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical