Basic Information
| Provider Information | |||||||||
| NPI: | 1497368419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BATCHELOR | ||||||||
| FirstName: | JAZMEN | ||||||||
| MiddleName: | MAKALA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 FAIRWAY DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334411817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774182978 | ||||||||
| FaxNumber: | 8665002168 | ||||||||
| Practice Location | |||||||||
| Address1: | 5175 OLD CLEMMONS SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367183960 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2020 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | MUJ352A22757 | 05 | NC | MEDICAID |