Provider Demographics
NPI:1184280570
Name:WHITE, JAZMIN A (MA)
Entity type:Individual
Prefix:
First Name:JAZMIN
Middle Name:A
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 COGGINS DR APT B109
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-4567
Mailing Address - Country:US
Mailing Address - Phone:707-805-1058
Mailing Address - Fax:
Practice Address - Street 1:5275 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1032
Practice Address - Country:US
Practice Address - Phone:510-428-3885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA162380Medicaid