Provider Demographics
NPI:1972390532
Name:LATAILLADE, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:LATAILLADE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 DALE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-1308
Mailing Address - Country:US
Mailing Address - Phone:516-376-7839
Mailing Address - Fax:
Practice Address - Street 1:703 DALE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-1308
Practice Address - Country:US
Practice Address - Phone:443-266-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21894101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health