Healthcare Provider Details

I. General information

NPI: 1114451051
Provider Name (Legal Business Name): JAZZMINE C BASHAM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAZZMINE C HERNANDEZ DO

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13570 N MAIN ST
TRENTON GA
30752-2012
US

IV. Provider business mailing address

13570 N MAIN ST
TRENTON GA
30752-2012
US

V. Phone/Fax

Practice location:
  • Phone: 706-956-2665
  • Fax: 706-657-2958
Mailing address:
  • Phone: 706-956-2665
  • Fax: 706-657-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP61126338
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6416
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number90864
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: