Provider Demographics
NPI:1376210112
Name:BAUTISTA, JASMINE SOFIA
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:SOFIA
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3344 LOCKHEED BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-2031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3344 LOCKHEED BLVD APT 1
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-2031
Practice Address - Country:US
Practice Address - Phone:703-618-1047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-28
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program