Provider Demographics
NPI:1649778895
Name:STEPHENSON, JAZMINE
Entity Type:Individual
Prefix:
First Name:JAZMINE
Middle Name:
Last Name:STEPHENSON
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 1:300 FAIRWAY DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DEERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:33441
Mailing Address - Country:US
Mailing Address - Phone:225-928-4040
Mailing Address - Fax:225-928-4111
Practice Address - Street 1:4201 N 1-10 SERVICE ROAD W
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:225-928-4111
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-06-11
Deactivation Date:2018-05-28
Deactivation Code:
Reactivation Date:2018-06-05
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health