Healthcare Provider Details

I. General information

NPI: 1346950755
Provider Name (Legal Business Name): JAZMIN TATYANA HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 WINCHESTER AVE
MARTINSBURG WV
25401-1683
US

IV. Provider business mailing address

PO BOX 442
SHEPHERDSTOWN WV
25443-0442
US

V. Phone/Fax

Practice location:
  • Phone: 304-290-4262
  • Fax: 304-212-0627
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: