Provider Demographics
NPI:1659055036
Name:SMALLS, JAZMINE
Entity Type:Individual
Prefix:
First Name:JAZMINE
Middle Name:
Last Name:SMALLS
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 1:966 GOVERNORS CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-9257
Mailing Address - Country:US
Mailing Address - Phone:843-813-1538
Mailing Address - Fax:888-813-3318
Practice Address - Street 1:2810 ASHLEY PHOSPHATE RD STE B11
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6406
Practice Address - Country:US
Practice Address - Phone:843-813-1538
Practice Address - Fax:888-813-3318
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-23-269792106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician