Provider Demographics
NPI:1699204933
Name:ROUNDTREE, JAZSMIN
Entity Type:Individual
Prefix:
First Name:JAZSMIN
Middle Name:
Last Name:ROUNDTREE
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 1:1400 MLK DR APT 39
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 MLK DR APT 39
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4889
Practice Address - Country:US
Practice Address - Phone:985-413-8731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA$$$$$$$$$Medicaid