Provider Demographics
NPI:1497242564
Name:HARRIS, JESSICA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2962 WOODCREST DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2962 WOODCREST DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2033
Practice Address - Country:US
Practice Address - Phone:850-896-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-15
Last Update Date:2018-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL50502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer