Provider Demographics
NPI:1316642564
Name:EVANS, JASMINE R
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:R
Last Name:EVANS
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 1:18927 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1061
Mailing Address - Country:US
Mailing Address - Phone:313-521-2677
Mailing Address - Fax:
Practice Address - Street 1:18927 KELLY RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1061
Practice Address - Country:US
Practice Address - Phone:313-521-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier