Healthcare Provider Details

I. General information

NPI: 1407775984
Provider Name (Legal Business Name): JASMINE MARYAM MIRDAMADI SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3590B PELHAM PKWY # 184
PELHAM AL
35124-2034
US

IV. Provider business mailing address

5440 COPPER CANYON RD UNIT C
YORBA LINDA CA
92887-3929
US

V. Phone/Fax

Practice location:
  • Phone: 775-525-8825
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number39061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: