Provider Demographics
NPI:1326613266
Name:HARRIS, JACQUELINE ROCHELLE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROCHELLE
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 1:333 GREAT RIVER RD APT 320
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1220
Mailing Address - Country:US
Mailing Address - Phone:770-296-0186
Mailing Address - Fax:
Practice Address - Street 1:45 DIMOCK ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-1208
Practice Address - Country:US
Practice Address - Phone:612-442-8800
Practice Address - Fax:617-442-4088
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859155122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty