Provider Demographics
NPI:1518943836
Name:JAZAYERI, MARY (NP, CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JAZAYERI
Suffix:
Gender:F
Credentials:NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:337-470-5239
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:4650 AMBASSADOR CAFFERY PKWY BLDG C
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6926
Practice Address - Country:US
Practice Address - Phone:337-470-5239
Practice Address - Fax:225-765-9886
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA223793176B00000X, 367A00000X
WI2198363L00000X
LAAP03263363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIS51922Medicare UPIN