Provider Demographics
NPI:1396470019
Name:HALL, JASMINE ALEXIS
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:ALEXIS
Last Name:HALL
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 1:1065 SW CANARY TER
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1818
Mailing Address - Country:US
Mailing Address - Phone:706-202-9024
Mailing Address - Fax:
Practice Address - Street 1:4203 SW HIGH MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3726
Practice Address - Country:US
Practice Address - Phone:772-225-5560
Practice Address - Fax:884-652-8088
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician