Provider Demographics
NPI:1558064493
Name:GANDARILLA, JAZMIN
Entity Type:Individual
Prefix:
First Name:JAZMIN
Middle Name:
Last Name:GANDARILLA
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 1:706 W DUG GAP MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-5613
Mailing Address - Country:US
Mailing Address - Phone:706-516-6303
Mailing Address - Fax:
Practice Address - Street 1:706 W DUG GAP MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-5613
Practice Address - Country:US
Practice Address - Phone:706-516-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator