Provider Demographics
NPI:1225372386
Name:FAMBRO, JASMINE ANNGENIKA (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:ANNGENIKA
Last Name:FAMBRO
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:ANNGENIKA
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:43740 N GROESBECK HWY
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1139
Mailing Address - Country:US
Mailing Address - Phone:586-469-7629
Mailing Address - Fax:586-466-4143
Practice Address - Street 1:43740 N GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1139
Practice Address - Country:US
Practice Address - Phone:586-469-7629
Practice Address - Fax:586-466-4143
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 106S00000X, 247200000X
MI6801097829104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other