Healthcare Provider Details

I. General information

NPI: 1790647014
Provider Name (Legal Business Name): JASMINE TODD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5885 KINGSTOWNE BLVD
ALEXANDRIA VA
22315-5702
US

IV. Provider business mailing address

5885 KINGSTOWNE BLVD
ALEXANDRIA VA
22315-5702
US

V. Phone/Fax

Practice location:
  • Phone: 703-922-0220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1101004346
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: