Basic Information
| Provider Information | |||||||||
| NPI: | 1619483674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | JASMINE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | |||||||||
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| OtherLastName: | MOON | ||||||||
| OtherFirstName: | JASMINE | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1921 WHITTLESEY RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319049211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065717771 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1921 WHITTLESEY RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319049211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065717771 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2017 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 110026265E | 05 | MA | MEDICAID |