Provider Demographics
NPI:1497338016
Name:HARRISON, JEREMY REED
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:REED
Last Name:HARRISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 GREEN OAKS LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-3421
Mailing Address - Country:US
Mailing Address - Phone:757-392-4087
Mailing Address - Fax:
Practice Address - Street 1:3409 GREEN OAKS LN
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-3421
Practice Address - Country:US
Practice Address - Phone:757-392-4087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLH620436762480207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH620436762480Medicaid