Provider Demographics
NPI:1609519149
Name:HARRISON, JENNIFER JOY
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOY
Last Name:HARRISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 N COUNTY ROAD 103
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-8086
Mailing Address - Country:US
Mailing Address - Phone:870-930-4132
Mailing Address - Fax:
Practice Address - Street 1:107 PARK ST
Practice Address - Street 2:
Practice Address - City:MC GEHEE
Practice Address - State:AR
Practice Address - Zip Code:71654-2915
Practice Address - Country:US
Practice Address - Phone:501-313-3389
Practice Address - Fax:501-614-1609
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0822Medicaid