Provider Demographics
NPI:1871914325
Name:HARRIS, JEAN
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-1574
Mailing Address - Country:US
Mailing Address - Phone:575-915-2424
Mailing Address - Fax:
Practice Address - Street 1:1000 POPLAR ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-1574
Practice Address - Country:US
Practice Address - Phone:575-915-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-01
Last Update Date:2014-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM64171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator