Provider Demographics
NPI:1962057463
Name:JASMIN, SHADOW (LCSW, LMT)
Entity type:Individual
Prefix:
First Name:SHADOW
Middle Name:
Last Name:JASMIN
Suffix:
Gender:
Credentials:LCSW, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 FOGGY MOUNTAIN PASS
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-2383
Mailing Address - Country:US
Mailing Address - Phone:608-409-3400
Mailing Address - Fax:
Practice Address - Street 1:251 PROGRESS WAY
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-2520
Practice Address - Country:US
Practice Address - Phone:608-409-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6526-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical