Provider Demographics
NPI:1528647351
Name:HARRISON, JERRY GLEN
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:GLEN
Last Name:HARRISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 HORSESHOE BND
Mailing Address - Street 2:
Mailing Address - City:HORACE
Mailing Address - State:ND
Mailing Address - Zip Code:58047-5717
Mailing Address - Country:US
Mailing Address - Phone:701-282-8152
Mailing Address - Fax:
Practice Address - Street 1:32 HORSESHOE BND
Practice Address - Street 2:
Practice Address - City:HORACE
Practice Address - State:ND
Practice Address - Zip Code:58047-5717
Practice Address - Country:US
Practice Address - Phone:701-282-8152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant