Healthcare Provider Details

I. General information

NPI: 1417306697
Provider Name (Legal Business Name): JAZZMON LEE NGUEDJO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JAZZMON SHERMAN OD

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 LORD BALTIMORE DR SUITE 300
BALTIMORE MD
21244-2653
US

IV. Provider business mailing address

2925 LORD BALTIMORE DR SUITE 300
BALTIMORE MD
21244-2653
US

V. Phone/Fax

Practice location:
  • Phone: 410-277-3937
  • Fax: 410-281-9388
Mailing address:
  • Phone: 410-277-3937
  • Fax: 410-281-9388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2536
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: