Provider Demographics
NPI:1558184697
Name:HARRIS, JERRY DOYLE
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:DOYLE
Last Name:HARRIS
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 1:2390 WEDGEWOOD DR UNIT 6250
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-2479
Mailing Address - Country:US
Mailing Address - Phone:888-238-1818
Mailing Address - Fax:855-915-1521
Practice Address - Street 1:101 PARK AVE STE 1300
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-7216
Practice Address - Country:US
Practice Address - Phone:405-689-9820
Practice Address - Fax:855-915-1521
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-24-390283106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician