=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972410918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASMINE T WILLIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2026
-----------------------------------------------------
Last Update Date | 08/25/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 CREEKVIEW BLVD
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30016-3084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-423-8892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 537 CENTRAL PARKWAY RD
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60098-2660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-423-8892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number | 14619682
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------