Provider Demographics
NPI:1194426072
Name:WILSON, JASMINE JANAE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:JANAE
Last Name:WILSON
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 1:5211 WINDSOR LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-5736
Mailing Address - Country:US
Mailing Address - Phone:772-418-6797
Mailing Address - Fax:
Practice Address - Street 1:1771 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5155
Practice Address - Country:US
Practice Address - Phone:702-560-2192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician