MEDICARE: MRS. JASMINE BLAKE HOLLYWOOD MS, LDN, CNS, ORDM

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	133N00000X	Nutritionist	ND11493	FL

General Provider Information

NPI Number	:	1588382949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JASMINE BLAKE HOLLYWOOD MS, LDN, CNS, ORDM

Provider Business Mailing Address
First Line	:	2021 N LEMANS BLVD UNIT 1121
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-1135
Country	:	US
Telephone Number	:	813-500-0085
Fax Number	:

Provider Business Practice Location Address
First Line	:	2021 N LEMANS BLVD UNIT 1121
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-1135
Country	:	US
Telephone Number	:	813-500-0085
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2022
Last Update Date	:	08/28/2022

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