Healthcare Provider Details

I. General information

NPI: 1699413963
Provider Name (Legal Business Name): JASMINE WARDLAW RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 SAWFISH CT
POINCIANA FL
34759-4806
US

IV. Provider business mailing address

52 SAWFISH CT
POINCIANA FL
34759-4806
US

V. Phone/Fax

Practice location:
  • Phone: 267-774-1625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-215519
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: