Provider Demographics
NPI:1487370185
Name:LAVERGNE, JAZMINE ANN (COTA)
Entity type:Individual
Prefix:
First Name:JAZMINE
Middle Name:ANN
Last Name:LAVERGNE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WILLOW TRACE DR
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36869-7105
Mailing Address - Country:US
Mailing Address - Phone:404-966-0479
Mailing Address - Fax:
Practice Address - Street 1:30 WILLOW TRACE DR
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36869-7105
Practice Address - Country:US
Practice Address - Phone:404-966-0479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002816224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant