Provider Demographics
NPI:1558833988
Name:BOGARTY, JASMINE
Entity Type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:
Last Name:BOGARTY
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 1:13211 SAYBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44105-7013
Mailing Address - Country:US
Mailing Address - Phone:216-466-2907
Mailing Address - Fax:
Practice Address - Street 1:13211 SAYBROOK AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44105-7013
Practice Address - Country:US
Practice Address - Phone:216-466-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-25
Last Update Date:2018-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.167828.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000000000000000000Medicaid