Provider Demographics
NPI:1659000743
Name:MAZIQUE, JASMINE (PTA)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:MAZIQUE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:
Other - Last Name:HUMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-305-2644
Mailing Address - Fax:
Practice Address - Street 1:33481 W 14 MILE RD STE 130
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-1578
Practice Address - Country:US
Practice Address - Phone:248-661-6708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009890225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant