Healthcare Provider Details

I. General information

NPI: 1831827625
Provider Name (Legal Business Name): MRS. JASAMYN NICHOLS DEGRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 COLLEGE VIEW DR
RICHMOND KY
40475-2403
US

IV. Provider business mailing address

203 COLLEGE VIEW DR
RICHMOND KY
40475-2403
US

V. Phone/Fax

Practice location:
  • Phone: 606-371-2935
  • Fax:
Mailing address:
  • Phone: 606-371-2935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: