Provider Demographics
NPI:1114451051
Name:BASHAM, JAZZMINE C (DO)
Entity Type:Individual
Prefix:
First Name:JAZZMINE
Middle Name:C
Last Name:BASHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JAZZMINE
Other - Middle Name:C
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:13570 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:GA
Mailing Address - Zip Code:30752-2012
Mailing Address - Country:US
Mailing Address - Phone:706-956-2665
Mailing Address - Fax:706-657-2958
Practice Address - Street 1:13570 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:GA
Practice Address - Zip Code:30752-2012
Practice Address - Country:US
Practice Address - Phone:706-956-2665
Practice Address - Fax:706-657-2958
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOP61126338207Q00000X
OK6416207Q00000X
GA90864207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000211956AMedicaid
WA0435237OtherLABOR AND INDUSTRIES