Provider Demographics
NPI:1538370291
Name:HARRIS, JACQULENE (FNP)
Entity type:Individual
Prefix:MRS
First Name:JACQULENE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-1203
Mailing Address - Country:US
Mailing Address - Phone:913-367-4879
Mailing Address - Fax:913-367-0240
Practice Address - Street 1:1412 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-1203
Practice Address - Country:US
Practice Address - Phone:913-367-4879
Practice Address - Fax:913-367-0240
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45573363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201072810AMedicaid