Provider Demographics
NPI:1609502657
Name:HARRIS, JEZWAH E (JD,MBA, NE-BC, MEP-C)
Entity Type:Individual
Prefix:DR
First Name:JEZWAH
Middle Name:E
Last Name:HARRIS
Suffix:
Gender:M
Credentials:JD,MBA, NE-BC, MEP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N GOULD ST STE 37558
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6317
Mailing Address - Country:US
Mailing Address - Phone:307-306-4535
Mailing Address - Fax:
Practice Address - Street 1:23440 CIVIC CENTER WAY STE 100
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-4855
Practice Address - Country:US
Practice Address - Phone:323-533-2624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-30
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9565726163W00000X, 363LP2300X, 390200000X
NVRN97140163WA2000X, 207N00000X
CA95101575163WC0200X, 163WA2000X, 163WE0003X, 207N00000X, 163WS0121X
NY789307163W00000X
WA61028225163W00000X
MA2340696163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WS0121XNursing Service ProvidersRegistered NursePlastic Surgery
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Multi-Specialty
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program