Provider Demographics
NPI:1609334515
Name:JEREMY N HARRIS, M.D., P.A.
Entity Type:Organization
Organization Name:JEREMY N HARRIS, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NOORJAHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-861-1330
Mailing Address - Street 1:943 CESERY BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-5655
Mailing Address - Country:US
Mailing Address - Phone:904-861-1330
Mailing Address - Fax:
Practice Address - Street 1:3636 UNIVERSITY BLVD S STE B3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4223
Practice Address - Country:US
Practice Address - Phone:904-448-3387
Practice Address - Fax:904-512-5235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-10
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055677700Medicaid