Healthcare Provider Details

I. General information

NPI: 1588228357
Provider Name (Legal Business Name): JASMINE GAINES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2019
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date: 08/17/2020
Reactivation Date: 09/01/2020

III. Provider practice location address

361 FALLS RD # 809
GRAFTON WI
53024-2617
US

IV. Provider business mailing address

361 FALLS RD # 809
GRAFTON WI
53024-2617
US

V. Phone/Fax

Practice location:
  • Phone: 262-290-5340
  • Fax:
Mailing address:
  • Phone: 262-290-5340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12197-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: