Provider Demographics
NPI:1376013599
Name:PETTWAY, JASMINE R (LMSW)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:R
Last Name:PETTWAY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MAIN ST STE 211
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-3230
Mailing Address - Country:US
Mailing Address - Phone:832-847-4836
Mailing Address - Fax:832-847-4852
Practice Address - Street 1:1601 MAIN ST STE 211
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-3230
Practice Address - Country:US
Practice Address - Phone:832-847-4836
Practice Address - Fax:832-847-4852
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty