Healthcare Provider Details

I. General information

NPI: 1629590286
Provider Name (Legal Business Name): MR. JACK BEVERLY HARRIS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 GREENGABLE WAY
CHESAPEAKE VA
23322
US

IV. Provider business mailing address

156 GREENGABLE WAY
CHESAPEAKE VA
23322-4278
US

V. Phone/Fax

Practice location:
  • Phone: 757-560-0231
  • Fax: 757-482-9033
Mailing address:
  • Phone: 757-560-0231
  • Fax: 757-482-9033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2705161949
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: