Healthcare Provider Details

I. General information

NPI: 1962485813
Provider Name (Legal Business Name): JACQUELINE K HARRIS ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W WASHINGTON ST
MONTEZUMA IA
50171-7739
US

IV. Provider business mailing address

PO BOX 430
MONTEZUMA IA
50171-0430
US

V. Phone/Fax

Practice location:
  • Phone: 641-623-5690
  • Fax:
Mailing address:
  • Phone: 641-623-5690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberA093734
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA093734
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: