Provider Demographics
NPI:1225601206
Name:SOURYAMAT, JAZMYN S (MA, BCBA, LABA)
Entity Type:Individual
Prefix:MS
First Name:JAZMYN
Middle Name:S
Last Name:SOURYAMAT
Suffix:
Gender:F
Credentials:MA, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 WALL ST APT C
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-3746
Mailing Address - Country:US
Mailing Address - Phone:231-499-4636
Mailing Address - Fax:
Practice Address - Street 1:35 WALL ST APT C
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-3746
Practice Address - Country:US
Practice Address - Phone:231-499-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3482103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA15189471OtherCAQH