Provider Demographics
NPI:1295140267
Name:HARRISON, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HARRISON
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 1:901 E. 104TH ST.
Mailing Address - Street 2:MAILSTOP 400N
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-9712
Mailing Address - Country:US
Mailing Address - Phone:816-502-7104
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:4061 INDIAN CREEK PKWY
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66207-4030
Practice Address - Country:US
Practice Address - Phone:913-323-4600
Practice Address - Fax:913-323-4748
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-40188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine