Provider Demographics
NPI:1497885628
Name:MOORE, JASMINA R (MFT)
Entity Type:Individual
Prefix:
First Name:JASMINA
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17635 GRAMA RDG
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-1359
Mailing Address - Country:US
Mailing Address - Phone:719-358-9332
Mailing Address - Fax:
Practice Address - Street 1:115 S PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3130
Practice Address - Country:US
Practice Address - Phone:719-447-4775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34960106H00000X
CO914106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist