Provider Demographics
NPI:1073052619
Name:HARRISON, JACQUELINE MARIE (ARNP-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 LAKE MARIAM WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-3818
Mailing Address - Country:US
Mailing Address - Phone:863-287-8864
Mailing Address - Fax:
Practice Address - Street 1:33044 HWY 27
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-7621
Practice Address - Country:US
Practice Address - Phone:863-422-4977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9243641363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology