=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912339037
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNI HARRIS DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2013
-----------------------------------------------------
Last Update Date | 02/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9305 W THOMAS RD STE 200
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85037-3447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-465-6693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3476 W MORGAN IVY LN
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85045-1102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-397-9349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 007978
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------