Healthcare Provider Details

I. General information

NPI: 1295543080
Provider Name (Legal Business Name): JASMINE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2024
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date: 04/08/2026
Reactivation Date: 05/11/2026

III. Provider practice location address

14912 MALLETT RD APT F301
BILOXI MS
39532-0026
US

IV. Provider business mailing address

768 CHERRY STONE DR
CLINTON MS
39056-2015
US

V. Phone/Fax

Practice location:
  • Phone: 601-397-9036
  • Fax:
Mailing address:
  • Phone: 601-397-9036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2150
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number800978630
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: