Provider Demographics
NPI:1962485813
Name:HARRIS, JACQUELINE K (ARNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:K
Last Name:HARRIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:IA
Mailing Address - Zip Code:50171-0430
Mailing Address - Country:US
Mailing Address - Phone:641-623-5690
Mailing Address - Fax:
Practice Address - Street 1:101 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:IA
Practice Address - Zip Code:50171-7739
Practice Address - Country:US
Practice Address - Phone:641-623-5690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA093734363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1962485813Medicaid
IA1962485813Medicaid