Provider Demographics
NPI:1912540238
Name:HARRIS, JEANNE CLACK (APRN)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:CLACK
Last Name:HARRIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-6437
Mailing Address - Country:US
Mailing Address - Phone:850-418-1730
Mailing Address - Fax:
Practice Address - Street 1:1717 N E ST STE 430
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6345
Practice Address - Country:US
Practice Address - Phone:850-437-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11003598363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106296100Medicaid