Provider Demographics
NPI:1508871195
Name:SHIPP, JASMINE DONNETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:JASMINE
Middle Name:DONNETTE
Last Name:SHIPP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2102
Mailing Address - Country:US
Mailing Address - Phone:662-843-8989
Mailing Address - Fax:
Practice Address - Street 1:710 N DAVIS AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2102
Practice Address - Country:US
Practice Address - Phone:662-843-8989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS720152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06484070Medicaid
MS410000356Medicare ID - Type Unspecified
MS06484070Medicaid