MEDICARE: JASMINE T MCKOY

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	1744P3200X	Prosthetics Case Management		NC

General Provider Information

NPI Number	:	1366121964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE T MCKOY

Provider Business Mailing Address
First Line	:	3507 KELBURN DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-2094
Country	:	US
Telephone Number	:	910-605-8107
Fax Number	:

Provider Business Practice Location Address
First Line	:	3507 KELBURN DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-2094
Country	:	US
Telephone Number	:	910-605-8107
Fax Number	:

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

Provider Enumeration Date	:	07/12/2023
Last Update Date	:	07/12/2023

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