Provider Demographics
NPI:1063614949
Name:HARRISON, JACQUELINE MICHELLE (HS)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MICHELLE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:HS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHURCH ST
Mailing Address - Street 2:APT. C
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-5050
Mailing Address - Country:US
Mailing Address - Phone:617-959-1271
Mailing Address - Fax:
Practice Address - Street 1:15 MOHEGAN AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-8100
Practice Address - Country:US
Practice Address - Phone:860-444-8402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider