Provider Demographics
NPI:1336236868
Name:HARRIS, JACQUELYNN CAROL (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:CAROL
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BRUTSCHER ST
Mailing Address - Street 2:D163
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-6096
Mailing Address - Country:US
Mailing Address - Phone:503-625-9190
Mailing Address - Fax:
Practice Address - Street 1:901 BRUTSCHER ST
Practice Address - Street 2:D163
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-6096
Practice Address - Country:US
Practice Address - Phone:503-625-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3747207Q00000X
ORDO29050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE94212Medicare UPIN