Provider Demographics
NPI:1841820255
Name:HARRIS, JEANETTA DOLORES
Entity type:Individual
Prefix:
First Name:JEANETTA
Middle Name:DOLORES
Last Name:HARRIS
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 1:5577 BLACK RD
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-5199
Mailing Address - Country:US
Mailing Address - Phone:850-693-4156
Mailing Address - Fax:
Practice Address - Street 1:5577 BLACK RD
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-5199
Practice Address - Country:US
Practice Address - Phone:850-693-4156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1651632163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management