Provider Demographics
NPI:1386152288
Name:JAMOUA, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:JAMOUA
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 1:5400 PERRY DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5400 PERRY DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3461
Practice Address - Country:US
Practice Address - Phone:248-674-7963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-14
Last Update Date:2018-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302043281183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist