Provider Demographics
NPI:1912512906
Name:TIMM, JASMINE ROSE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:ROSE
Last Name:TIMM
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:PO BOX 26832
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-6832
Mailing Address - Country:US
Mailing Address - Phone:541-505-1215
Mailing Address - Fax:
Practice Address - Street 1:755 HIGHLAND OAKS DR STE 105
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7106
Practice Address - Country:US
Practice Address - Phone:336-370-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16801101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health