Provider Demographics
NPI:1588382949
Name:HOLLYWOOD, JASMINE BLAKE (MS, LDN, CNS, ORDM)
Entity type:Individual
Prefix:MRS
First Name:JASMINE
Middle Name:BLAKE
Last Name:HOLLYWOOD
Suffix:
Gender:F
Credentials:MS, LDN, CNS, ORDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 N LEMANS BLVD UNIT 1121
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1135
Mailing Address - Country:US
Mailing Address - Phone:813-500-0085
Mailing Address - Fax:
Practice Address - Street 1:2021 N LEMANS BLVD UNIT 1121
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1135
Practice Address - Country:US
Practice Address - Phone:813-500-0085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND11493133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist