1679572762 NPI number — DR. JENNIFER MARIE HARRIS M.D.

Table of content: DR. JENNIFER MARIE HARRIS M.D. (NPI 1679572762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679572762 NPI number — DR. JENNIFER MARIE HARRIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
JENNIFER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679572762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12525 PERKINS RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70810-1907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-769-2003
Provider Business Mailing Address Fax Number:
225-767-3055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12525 PERKINS RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70810-1907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-769-2003
Provider Business Practice Location Address Fax Number:
225-767-3055
Provider Enumeration Date:
07/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  15568R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1464121 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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