Basic Information
| Provider Information | |||||||||
| NPI: | 1336502897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERDER | ||||||||
| FirstName: | JAYME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 OLD MANLY CT | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523755194 | ||||||||
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| Practice Location | |||||||||
| Address1: | 720 WESTVIEW DR. SW | ||||||||
| Address2: | MOREHOUSE SCHOOL OF MEDICINE GME | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561393 | ||||||||
| FaxNumber: | 4047561357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2016 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.