Healthcare Provider Details

I. General information

NPI: 1316672322
Provider Name (Legal Business Name): JASMINE ANTHONY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 BLADES FARM RD STE 202
DENTON MD
21629-3489
US

IV. Provider business mailing address

1140 BLADES FARM RD
DENTON MD
21629-3488
US

V. Phone/Fax

Practice location:
  • Phone: 410-204-4554
  • Fax:
Mailing address:
  • Phone: 302-519-3130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number28719
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28719
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: