Provider Demographics
NPI:1417396102
Name:ROSS, JASMINE LATASHA
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:LATASHA
Last Name:ROSS
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 1:1755 SOTO ST
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-3941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1069 BROADWAY AVE
Practice Address - Street 2:SUITE201
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-4996
Practice Address - Country:US
Practice Address - Phone:831-392-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable