Provider Demographics
NPI:1891329686
Name:WITHERS, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:WITHERS
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 1:45835 BROWNELL ST
Mailing Address - Street 2:APT 9
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317
Mailing Address - Country:US
Mailing Address - Phone:586-277-4455
Mailing Address - Fax:
Practice Address - Street 1:45835 BROWNELL ST
Practice Address - Street 2:APT 9
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317
Practice Address - Country:US
Practice Address - Phone:586-277-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIW362373777067172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver