=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366586422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASMINE JEFFERS, MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 07/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3825 MEDICAL PARK DR SUITE 300
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-941-4810
-----------------------------------------------------
Fax | 770-948-9149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 650
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30168-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-941-4810
-----------------------------------------------------
Fax | 770-948-9149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MR. DEVON CHARLES SPENCER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-941-4810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------