Healthcare Provider Details

I. General information

NPI: 1770352726
Provider Name (Legal Business Name): JASMINE CUCINOTTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2024
Last Update Date: 01/01/2024
Certification Date: 12/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 SURFBIRD RD
SUMMERVILLE SC
29486-5446
US

IV. Provider business mailing address

145 SURFBIRD RD
SUMMERVILLE SC
29486-5446
US

V. Phone/Fax

Practice location:
  • Phone: 240-925-8444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25995
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: