Provider Demographics
NPI:1881167880
Name:WILLIS, JAZZMINE ELAYNE
Entity type:Individual
Prefix:
First Name:JAZZMINE
Middle Name:ELAYNE
Last Name:WILLIS
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 1:3381 GLADE CREEK BLVD NE APT 9
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-8671
Mailing Address - Country:US
Mailing Address - Phone:843-473-5827
Mailing Address - Fax:
Practice Address - Street 1:80 WESTLAKE RD
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:VA
Practice Address - Zip Code:24101-3954
Practice Address - Country:US
Practice Address - Phone:540-721-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202216949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist