Provider Demographics
NPI:1336196641
Name:BAZAN, JENNIFER A
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BAZAN
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 1:5104 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-2119
Mailing Address - Country:US
Mailing Address - Phone:469-323-7962
Mailing Address - Fax:
Practice Address - Street 1:8400 N MOPAC EXPY
Practice Address - Street 2:SUITE 302
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8328
Practice Address - Country:US
Practice Address - Phone:512-213-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19844101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176552101Medicaid