Provider Demographics
NPI:1669130381
Name:MOORE, JASMINE MARIE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:MARIE
Last Name:MOORE
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 1:2180 WILLIAM S. WHITE BUILDING
Mailing Address - Street 2:303 E KEARSLEY STREET
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-1950
Mailing Address - Country:US
Mailing Address - Phone:810-762-3420
Mailing Address - Fax:
Practice Address - Street 1:3400 N 29TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-1002
Practice Address - Country:US
Practice Address - Phone:954-276-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704318940163W00000X
FL9475967163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse