Healthcare Provider Details

I. General information

NPI: 1215422043
Provider Name (Legal Business Name): JACQUELINE HARRIS, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SEAGRASS STATION RD
BLUFFTON SC
29910-3110
US

IV. Provider business mailing address

PO BOX 14624
SAVANNAH GA
31416-1624
US

V. Phone/Fax

Practice location:
  • Phone: 836-843-8200
  • Fax: 843-836-8595
Mailing address:
  • Phone: 843-422-4413
  • Fax: 866-848-1697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE HARRIS
Title or Position: OWNER
Credential: MD
Phone: 843-422-4413