Provider Demographics
NPI:1780298604
Name:MACK, JASMINE KENYATTA (MS)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:KENYATTA
Last Name:MACK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:KENYATTA
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:3105 CLAIRMONT RD NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-1015
Practice Address - Country:US
Practice Address - Phone:470-241-1353
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-130813106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician