Provider Demographics
NPI:1265102792
Name:DAVIS, JASMINE CARNISE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:CARNISE
Last Name:DAVIS
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 1:351 MCKAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1518
Mailing Address - Country:US
Mailing Address - Phone:252-657-8875
Mailing Address - Fax:
Practice Address - Street 1:1775 WEST STATE ROAD 434 LONGWOOD
Practice Address - Street 2:SEMIONOLE
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:32750
Practice Address - Country:US
Practice Address - Phone:407-919-6845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician