MEDICARE: JASMINE LEANDRA WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1164289914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE LEANDRA WILSON

Provider Business Mailing Address
First Line	:	6724 BRIARCREEK DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-7426
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6724 BRIARCREEK DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-7426
Country	:	US
Telephone Number	:	405-479-2691
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2024
Last Update Date	:	02/19/2026

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