Healthcare Provider Details

I. General information

NPI: 1376474486
Provider Name (Legal Business Name): ALEXIS JASMINE SMALL RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 TOWNE PARK DR
RINCON GA
31326-9368
US

IV. Provider business mailing address

430 WEISENBAKER RD APT 31
RINCON GA
31326-9029
US

V. Phone/Fax

Practice location:
  • Phone: 912-208-4776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number853353346
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: