Provider Demographics
NPI:1386307718
Name:POLK, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:POLK
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 1:20056 IRVINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203
Mailing Address - Country:US
Mailing Address - Phone:313-955-1416
Mailing Address - Fax:
Practice Address - Street 1:20056 IRVINGTON STREET
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203
Practice Address - Country:US
Practice Address - Phone:313-955-1416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8129980Medicaid