Healthcare Provider Details

I. General information

NPI: 1942637905
Provider Name (Legal Business Name): JACQUELYN HARRISON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 SUNDAY DR STE 200
RALEIGH NC
27607-6000
US

IV. Provider business mailing address

6637 KEYSTONE DR
RALEIGH NC
27612-5209
US

V. Phone/Fax

Practice location:
  • Phone: 919-859-9040
  • Fax: 919-859-9030
Mailing address:
  • Phone: 919-247-2906
  • Fax: 800-213-8256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3729
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: