Provider Demographics
NPI:1881316669
Name:KING, JAZMINE S
Entity type:Individual
Prefix:
First Name:JAZMINE
Middle Name:S
Last Name:KING
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 1:303 N ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-3658
Mailing Address - Country:US
Mailing Address - Phone:318-517-0308
Mailing Address - Fax:
Practice Address - Street 1:23 E ROSS AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6423
Practice Address - Country:US
Practice Address - Phone:918-227-2016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes175T00000XOther Service ProvidersPeer Specialist