Provider Demographics
NPI:1861952012
Name:ROBERTS, JAZZMYN CHARRISSE DIANE
Entity type:Individual
Prefix:MS
First Name:JAZZMYN
Middle Name:CHARRISSE DIANE
Last Name:ROBERTS
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 1:900 E MAIN ST BLDG 52
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-5305
Mailing Address - Country:US
Mailing Address - Phone:405-307-4811
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST BLDG 52
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5305
Practice Address - Country:US
Practice Address - Phone:405-307-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2019-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health