Healthcare Provider Details

I. General information

NPI: 1023708344
Provider Name (Legal Business Name): JAZMINE VAZ-BAKER LGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 JOHNSON FY RD NE STE 350
ATLANTA GA
30342-1740
US

IV. Provider business mailing address

8023 GABLES LN
ATLANTA GA
30350-5046
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-6284
  • Fax: 404-303-3878
Mailing address:
  • Phone: 813-300-9814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number483
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: