Provider Demographics
NPI:1386474377
Name:JASPER 1692 LLC
Entity type:Organization
Organization Name:JASPER 1692 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-215-0209
Mailing Address - Street 1:3015 COUNTRY BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33567-8606
Mailing Address - Country:US
Mailing Address - Phone:813-215-0209
Mailing Address - Fax:
Practice Address - Street 1:3015 COUNTRY BREEZE DR
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33567-8606
Practice Address - Country:US
Practice Address - Phone:813-215-0209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty