Healthcare Provider Details

I. General information

NPI: 1477194017
Provider Name (Legal Business Name): JASMYNE R VANBUREN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 WALTON RD
DEFUNIAK SPGS FL
32433-9503
US

IV. Provider business mailing address

2547 ANGEL CT
GULF BREEZE FL
32563-5552
US

V. Phone/Fax

Practice location:
  • Phone: 850-741-6715
  • Fax: 850-204-0489
Mailing address:
  • Phone: 850-741-6715
  • Fax: 850-204-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number17110
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA17110
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number25696
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: