Provider Demographics
NPI:1134894686
Name:FORTMAN, JAZMYNE ELAINE
Entity type:Individual
Prefix:
First Name:JAZMYNE
Middle Name:ELAINE
Last Name:FORTMAN
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 1:16899 JAMBOREE RD APT 328
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-3185
Mailing Address - Country:US
Mailing Address - Phone:714-472-7428
Mailing Address - Fax:
Practice Address - Street 1:238 S FLOWER ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3415
Practice Address - Country:US
Practice Address - Phone:714-472-7428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126808106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist