Provider Demographics
NPI:1962726240
Name:HARRIS, JENNIFER H (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:H
Last Name:HARRIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 S DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93437-6307
Mailing Address - Country:US
Mailing Address - Phone:805-606-6117
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:VANDENBERG AFB
Practice Address - State:CA
Practice Address - Zip Code:93437
Practice Address - Country:US
Practice Address - Phone:805-606-6117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CA26018103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist