=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578212999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASMINE DAVIS MSW, LCSWA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2022
-----------------------------------------------------
Last Update Date | 03/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 351 WAGONER DR STE 175
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-4860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-673-3535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2628 LULL WATER DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28306-4555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-229-6905
-----------------------------------------------------
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 | P016021
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------