Provider Demographics
NPI:1922243476
Name:HARRIS, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
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 1:5239 FORTRESS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-242-9255
Mailing Address - Fax:
Practice Address - Street 1:5239 FORTRESS CIR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-6569
Practice Address - Country:US
Practice Address - Phone:229-242-9255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001102106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist