Healthcare Provider Details

I. General information

NPI: 1134919079
Provider Name (Legal Business Name): JASMINE DAVIS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SUPERIOR DR
SPRING LAKE NC
28390-3190
US

IV. Provider business mailing address

1912 STACKHOUSE DR
FAYETTEVILLE NC
28314-6903
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-1711
  • Fax:
Mailing address:
  • Phone: 910-301-7226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-447743
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: