Provider Demographics
NPI:1902177496
Name:HARRIS, JENNIFER BROOKE (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BROOKE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MEDICAL CENTER DR STE 405
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7914
Mailing Address - Country:US
Mailing Address - Phone:270-441-4750
Mailing Address - Fax:270-441-4770
Practice Address - Street 1:225 MEDICAL CENTER DR STE 405
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7914
Practice Address - Country:US
Practice Address - Phone:270-441-4750
Practice Address - Fax:270-441-4770
Is Sole Proprietor?:No
Enumeration Date:2012-01-16
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007292367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100196050Medicaid
KYK032180Medicare PIN
KY7100196050Medicaid