MEDICARE: JASPER 1692 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1386474377
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JASPER 1692 LLC

Provider Business Mailing Address
First Line	:	3015 COUNTRY BREEZE DR
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33567-8606
Country	:	US
Telephone Number	:	813-215-0209
Fax Number	:

Provider Business Practice Location Address
First Line	:	3015 COUNTRY BREEZE DR
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33567-8606
Country	:	US
Telephone Number	:	813-215-0209
Fax Number	:

Authorized Official
Title or Position	:	LCSW
Name	:	ALISON MOORE
Credential	:
Telephone Number	:	813-215-0209

Provider Enumeration Date	:	08/05/2024
Last Update Date	:	08/05/2024

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Directions to “JASPER 1692 LLC ” Practice Location

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