Provider Demographics
NPI:1750142477
Name:HARRIS, JEROME SR
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:HARRIS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S CICERO AVE # 2R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4926
Mailing Address - Country:US
Mailing Address - Phone:708-864-7023
Mailing Address - Fax:
Practice Address - Street 1:309 S CICERO AVE # 2R
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-4926
Practice Address - Country:US
Practice Address - Phone:708-864-7023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)