Healthcare Provider Details

I. General information

NPI: 1114719481
Provider Name (Legal Business Name): JASMINE SMITH
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S TANGERINE CT
EAGLE LAKE FL
33839-3510
US

IV. Provider business mailing address

405 S TANGERINE CT
EAGLE LAKE FL
33839-3510
US

V. Phone/Fax

Practice location:
  • Phone: 863-589-3007
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI6993
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: