Provider Demographics
NPI:1790449031
Name:BYNES, JASMINE (MA1,PH1, NTI)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:BYNES
Suffix:
Gender:F
Credentials:MA1,PH1, NTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 NORTH ST E
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8721
Mailing Address - Country:US
Mailing Address - Phone:912-380-2228
Mailing Address - Fax:
Practice Address - Street 1:214 W MAIN ST STE 214A
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3150
Practice Address - Country:US
Practice Address - Phone:912-245-9332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACOI-002022174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist