Healthcare Provider Details

I. General information

NPI: 1770079964
Provider Name (Legal Business Name): JASMINE RANGE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 AIRPORT RD
JACKSON MI
49202-1872
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-499-2976
  • Fax:
Mailing address:
  • Phone: 517-676-9788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801106362
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801100971
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: