Provider Demographics
NPI:1871688473
Name:HARRISON, MICHAEL JAY (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 E. OHIO
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735
Mailing Address - Country:US
Mailing Address - Phone:660-885-3981
Mailing Address - Fax:
Practice Address - Street 1:704 E. OHIO
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735
Practice Address - Country:US
Practice Address - Phone:660-885-3981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU56223Medicare UPIN