Healthcare Provider Details

I. General information

NPI: 1326613266
Provider Name (Legal Business Name): JACQUELINE ROCHELLE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 DIMOCK ST
BOSTON MA
02119-1208
US

IV. Provider business mailing address

333 GREAT RIVER RD APT 320
SOMERVILLE MA
02145-1220
US

V. Phone/Fax

Practice location:
  • Phone: 612-442-8800
  • Fax: 617-442-4088
Mailing address:
  • Phone: 770-296-0186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1859155
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: