Healthcare Provider Details

I. General information

NPI: 1285100818
Provider Name (Legal Business Name): JASMINE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 US HIGHWAY 301 S STE 5
RIVERVIEW FL
33578-3572
US

IV. Provider business mailing address

3165 GRAND AVE APT 402
PINELLAS PARK FL
33782-6147
US

V. Phone/Fax

Practice location:
  • Phone: 813-246-3186
  • Fax:
Mailing address:
  • Phone: 904-861-9278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5603
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: