Healthcare Provider Details

I. General information

NPI: 1881235018
Provider Name (Legal Business Name): JAZZMYN PROCTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2019
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 30TH ST SE
WASHINGTON DC
20019-1167
US

IV. Provider business mailing address

1004 30TH ST SE
WASHINGTON DC
20019-1167
US

V. Phone/Fax

Practice location:
  • Phone: 301-789-8228
  • Fax:
Mailing address:
  • Phone: 301-789-8228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC200012918
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: