Healthcare Provider Details

I. General information

NPI: 1376622126
Provider Name (Legal Business Name): JACK MICHAEL HARLESS D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7677 PARAGON RD # D1
CENTERVILLE FINANCE OH
45459-4068
US

IV. Provider business mailing address

7185 BIGGER LN
CENTERVILLE FINANCE OH
45459-4907
US

V. Phone/Fax

Practice location:
  • Phone: 937-435-8480
  • Fax:
Mailing address:
  • Phone: 937-433-7328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3061
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: