Provider Demographics
NPI:1013225283
Name:HARRIS, JEANETTE NECOLE (IDMT)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:NECOLE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 SAVANNAH WAY APT 202
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1381 S PATRICK DR
Practice Address - Street 2:
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3606
Practice Address - Country:US
Practice Address - Phone:321-494-8191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians