Healthcare Provider Details

I. General information

NPI: 1952022162
Provider Name (Legal Business Name): JAMESRIA A HARRIS LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAM HARRIS LAC

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 N 30TH AVE
PHOENIX AZ
85017-4607
US

IV. Provider business mailing address

7141 W CARTER RD
LAVEEN AZ
85339-7059
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-6143
  • Fax: 480-781-4566
Mailing address:
  • Phone: 503-890-0311
  • Fax: 480-781-4566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC19969
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: