Provider Demographics
NPI:1831873330
Name:HARRIS, JENNIFER L (BA PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:HARRIS
Suffix:
Gender:F
Credentials:BA PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LAKESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:NC
Mailing Address - Zip Code:28630-1723
Mailing Address - Country:US
Mailing Address - Phone:828-291-4460
Mailing Address - Fax:
Practice Address - Street 1:104 GEORGE BISHOP PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-7335
Practice Address - Country:US
Practice Address - Phone:828-291-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone