Provider Demographics
NPI:1710748017
Name:KOUSSA, JASMINE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:KOUSSA
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 1:127 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1210
Mailing Address - Country:US
Mailing Address - Phone:248-573-7417
Mailing Address - Fax:
Practice Address - Street 1:127 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1210
Practice Address - Country:US
Practice Address - Phone:248-573-7417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0000000000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker