Provider Demographics
NPI:1124789482
Name:BERRY, JAZMYNE TAYLOR
Entity type:Individual
Prefix:
First Name:JAZMYNE
Middle Name:TAYLOR
Last Name:BERRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2930
Mailing Address - Country:US
Mailing Address - Phone:802-886-8902
Mailing Address - Fax:
Practice Address - Street 1:90 VANDENBERG DR
Practice Address - Street 2:
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2104
Practice Address - Country:US
Practice Address - Phone:781-225-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031642363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program