Provider Demographics
NPI:1558151175
Name:WISE, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:WISE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5638
Mailing Address - Country:US
Mailing Address - Phone:302-824-5889
Mailing Address - Fax:
Practice Address - Street 1:77 W BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5638
Practice Address - Country:US
Practice Address - Phone:302-824-5889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH007700103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst