Provider Demographics
NPI:1376622126
Name:HARLESS, JACK MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MICHAEL
Last Name:HARLESS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7185 BIGGER LN
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE FINANCE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4907
Mailing Address - Country:US
Mailing Address - Phone:937-433-7328
Mailing Address - Fax:
Practice Address - Street 1:7677 PARAGON RD # D1
Practice Address - Street 2:
Practice Address - City:CENTERVILLE FINANCE
Practice Address - State:OH
Practice Address - Zip Code:45459-4068
Practice Address - Country:US
Practice Address - Phone:937-435-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3061111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH296740715-00OtherOBWC