Provider Demographics
NPI:1093460594
Name:AVITIA, JASMINE NICOLE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:NICOLE
Last Name:AVITIA
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 1:3404 N LECANTO HWY STE D
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3569
Mailing Address - Country:US
Mailing Address - Phone:208-484-0907
Mailing Address - Fax:
Practice Address - Street 1:3404 N LECANTO HWY STE D
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3569
Practice Address - Country:US
Practice Address - Phone:352-419-4856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health