Provider Demographics
NPI:1750843876
Name:HARRIS, JEREL KEITH (NP-C)
Entity type:Individual
Prefix:
First Name:JEREL
Middle Name:KEITH
Last Name:HARRIS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1677 ARCHER ESTATES DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-8101
Mailing Address - Country:US
Mailing Address - Phone:478-228-8506
Mailing Address - Fax:
Practice Address - Street 1:1677 ARCHER ESTATES DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-8101
Practice Address - Country:US
Practice Address - Phone:478-228-8506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-06
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165803363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care