Provider Demographics
NPI:1881235018
Name:PROCTOR, JAZZMYN
Entity type:Individual
Prefix:
First Name:JAZZMYN
Middle Name:
Last Name:PROCTOR
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 1:6318 STATUM RD
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:MD
Mailing Address - Zip Code:21655-2011
Mailing Address - Country:US
Mailing Address - Phone:301-789-8228
Mailing Address - Fax:
Practice Address - Street 1:6318 STATUM RD
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:MD
Practice Address - Zip Code:21655-2011
Practice Address - Country:US
Practice Address - Phone:301-789-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician