Healthcare Provider Details

I. General information

NPI: 1780799395
Provider Name (Legal Business Name): JUDITH ANN HARRISON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1833 BOULEVARD
JACKSONVILLE FL
32206-4382
US

IV. Provider business mailing address

4235 HEATH RD
JACKSONVILLE FL
32277-1587
US

V. Phone/Fax

Practice location:
  • Phone: 904-232-2751
  • Fax:
Mailing address:
  • Phone: 904-745-0136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number35-05-1388-T
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: