Healthcare Provider Details

I. General information

NPI: 1710720065
Provider Name (Legal Business Name): MRS. JAZMIN RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 STANTON WOODS DR SE
CONYERS GA
30094-2672
US

IV. Provider business mailing address

2717 STANTON WOODS DR SE
CONYERS GA
30094-2672
US

V. Phone/Fax

Practice location:
  • Phone: 470-343-4698
  • Fax:
Mailing address:
  • Phone: 470-343-4698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: