Provider Demographics
NPI:1598565830
Name:HARRIS, JACQUETTA I (MSW, LCSWA)
Entity type:Individual
Prefix:
First Name:JACQUETTA
Middle Name:I
Last Name:HARRIS
Suffix:
Gender:
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 561372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28256-1372
Mailing Address - Country:US
Mailing Address - Phone:704-777-4361
Mailing Address - Fax:
Practice Address - Street 1:1515 MOCKINGBIRD LN STE 420
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3236
Practice Address - Country:US
Practice Address - Phone:980-304-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0217131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical