MEDICARE: JASMINE M PUGH

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	390200000X	Student in an Organized Health Care Education/Training Program
2	225XM0800X	Mental Health Occupational Therapist	124661	CA

General Provider Information

NPI Number	:	1962196709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE M PUGH

Provider Business Mailing Address
First Line	:	640 BAILEY RD # 448
Second Line	:
City	:	BAY POINT
State	:	CA
Zip	:	94565-4306
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	640 BAILEY RD # 448
Second Line	:
City	:	BAY POINT
State	:	CA
Zip	:	94565-4306
Country	:	US
Telephone Number	:	510-290-1577
Fax Number	:

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

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	09/24/2024

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