Provider Demographics
NPI:1790390342
Name:HARRIS, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
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 1:193 SOUTHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAVISVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26142-8918
Mailing Address - Country:US
Mailing Address - Phone:304-494-8374
Mailing Address - Fax:
Practice Address - Street 1:193 SOUTHRIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVISVILLE
Practice Address - State:WV
Practice Address - Zip Code:26142-8918
Practice Address - Country:US
Practice Address - Phone:304-494-8374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant