Provider Demographics
NPI:1215359658
Name:BLACK, JASMINE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:BLACK
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 1:6119 MIDTOWN AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5313
Mailing Address - Country:US
Mailing Address - Phone:501-664-4532
Mailing Address - Fax:501-663-4335
Practice Address - Street 1:6119 MIDTOWN AVE
Practice Address - Street 2:STE 201
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5313
Practice Address - Country:US
Practice Address - Phone:501-664-4532
Practice Address - Fax:501-663-4335
Is Sole Proprietor?:No
Enumeration Date:2014-01-18
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR078727163W00000X
ARC003006367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse