Provider Demographics
NPI:1043062078
Name:WILLIS, JASMINE DEANNA (RBT)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:DEANNA
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10014 PARK PLACE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-5303
Mailing Address - Country:US
Mailing Address - Phone:813-515-6323
Mailing Address - Fax:
Practice Address - Street 1:10014 PARK PLACE AVE
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-5303
Practice Address - Country:US
Practice Address - Phone:813-515-6323
Practice Address - Fax:813-515-6373
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1096735106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician