Provider Demographics
NPI:1619483674
Name:MOON, JASMINE S
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:S
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:S
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1921 WHITTLESEY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-9211
Mailing Address - Country:US
Mailing Address - Phone:706-571-7771
Mailing Address - Fax:
Practice Address - Street 1:1921 WHITTLESEY RD STE 400
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9211
Practice Address - Country:US
Practice Address - Phone:706-571-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid