Healthcare Provider Details

I. General information

NPI: 1124511704
Provider Name (Legal Business Name): JESSICA HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MELBOURNE RD
CHARLOTTESVILLE VA
22901-3148
US

IV. Provider business mailing address

26 TANGLEWOOD RD
PALMYRA VA
22963-3316
US

V. Phone/Fax

Practice location:
  • Phone: 434-245-2400
  • Fax:
Mailing address:
  • Phone: 253-259-4991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPPS-0604986
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: