Basic Information
| Provider Information | |||||||||
| NPI: | 1073052619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | ARNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 LAKE MARIAM WAY | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338843818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632878864 | ||||||||
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| Practice Location | |||||||||
| Address1: | 33044 HWY 27 | ||||||||
| Address2: | |||||||||
| City: | HAINES CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338447621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634224977 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2017 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 9243641 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | 9243641 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.