=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407433840
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASMINE S IVERSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2021
-----------------------------------------------------
Last Update Date | 03/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 S MCDOWELL ST STE 125-1325
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-317-3529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 NEWFOUND HOLLOW DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28214-4502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-317-3529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C015674
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------