Provider Demographics
NPI:1194524637
Name:MOON-WOODBURY, JASMINE R
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:R
Last Name:MOON-WOODBURY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2996 STREAM VW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-7981
Mailing Address - Country:US
Mailing Address - Phone:770-309-0540
Mailing Address - Fax:
Practice Address - Street 1:2996 STREAM VW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-7981
Practice Address - Country:US
Practice Address - Phone:770-309-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-08
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT013530225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist