Healthcare Provider Details

I. General information

NPI: 1760098610
Provider Name (Legal Business Name): JASMINE HEPBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 PINE MARSH LOOP
SAINT CLOUD FL
34771-7407
US

IV. Provider business mailing address

1521 PINE MARSH LOOP
SAINT CLOUD FL
34771-7407
US

V. Phone/Fax

Practice location:
  • Phone: 407-731-2425
  • Fax:
Mailing address:
  • Phone: 407-731-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number69497
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: