Provider Demographics
NPI:1073351037
Name:FERNANDEZ, JAZMINE DULCINEA (BA)
Entity type:Individual
Prefix:
First Name:JAZMINE
Middle Name:DULCINEA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 PRUDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-5412
Mailing Address - Country:US
Mailing Address - Phone:401-626-9916
Mailing Address - Fax:
Practice Address - Street 1:1052 PARK AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-3225
Practice Address - Country:US
Practice Address - Phone:401-462-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00985101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)