Provider Demographics
NPI:1821647157
Name:POOLE, JASMINE NICOLE (MS)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:NICOLE
Last Name:POOLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 JETT LN
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-8645
Mailing Address - Country:US
Mailing Address - Phone:813-900-1917
Mailing Address - Fax:
Practice Address - Street 1:2202 MANDARIN LOOP
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:FL
Practice Address - Zip Code:33838-4387
Practice Address - Country:US
Practice Address - Phone:833-869-2423
Practice Address - Fax:863-869-6727
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-19-98037OtherREGISTERED BEHAVIOR TECHNICIAN
FL104157700Medicaid