Provider Demographics
NPI:1407348477
Name:HARAHUS, JACQUELINE MAE (LPN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MAE
Last Name:HARAHUS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 GLEN MARY DR LOT 1
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-2013
Mailing Address - Country:US
Mailing Address - Phone:607-658-6369
Mailing Address - Fax:
Practice Address - Street 1:413 GLEN MARY DR LOT 1
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-2013
Practice Address - Country:US
Practice Address - Phone:607-658-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265390164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse