Provider Demographics
NPI:1215422043
Name:JACQUELINE HARRIS, MD, LLC
Entity type:Organization
Organization Name:JACQUELINE HARRIS, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-422-4413
Mailing Address - Street 1:PO BOX 14624
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-1624
Mailing Address - Country:US
Mailing Address - Phone:843-422-4413
Mailing Address - Fax:866-848-1697
Practice Address - Street 1:107 SEAGRASS STATION RD
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-3110
Practice Address - Country:US
Practice Address - Phone:836-843-8200
Practice Address - Fax:843-836-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC52695OtherMEDICAL LICENSE