Provider Demographics
NPI:1295368090
Name:HARASEWICZ, JACKIE ANNE (OMT)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:ANNE
Last Name:HARASEWICZ
Suffix:
Gender:F
Credentials:OMT
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:ANNE
Other - Last Name:STOCKTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OMT
Mailing Address - Street 1:504 LOST OAK LN
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-8345
Mailing Address - Country:US
Mailing Address - Phone:269-753-8213
Mailing Address - Fax:
Practice Address - Street 1:213 N PAW PAW ST
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038-9589
Practice Address - Country:US
Practice Address - Phone:269-753-8213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902016477124Q00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty