Healthcare Provider Details

I. General information

NPI: 1801764907
Provider Name (Legal Business Name): JASMINE SHAREE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 JAN LN
DE SOTO IL
62924-0059
US

IV. Provider business mailing address

90 JAN LN
DE SOTO IL
62924-0059
US

V. Phone/Fax

Practice location:
  • Phone: 618-645-1211
  • Fax:
Mailing address:
  • Phone: 618-645-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209033596
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: