Provider Demographics
NPI:1417608506
Name:WILSON, JAZMIN (LPN)
Entity Type:Individual
Prefix:MS
First Name:JAZMIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 E TREASURE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH BAY VILLAGE
Mailing Address - State:FL
Mailing Address - Zip Code:33141-4373
Mailing Address - Country:US
Mailing Address - Phone:305-215-2984
Mailing Address - Fax:
Practice Address - Street 1:7525 E TREASURE DR
Practice Address - Street 2:
Practice Address - City:NORTH BAY VILLAGE
Practice Address - State:FL
Practice Address - Zip Code:33141-4373
Practice Address - Country:US
Practice Address - Phone:305-215-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019015909164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA