Provider Demographics
NPI:1619693348
Name:HARRIS, JACQUELINE ANN
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:HARRIS
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 1:309 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-2822
Mailing Address - Country:US
Mailing Address - Phone:865-414-2881
Mailing Address - Fax:
Practice Address - Street 1:309 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-2822
Practice Address - Country:US
Practice Address - Phone:865-414-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3048225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3548OtherDEPARTMENT OF HEALTH
TN4578316OtherDOH