Provider Demographics
NPI:1902355043
Name:KORDBACHEH, JASMINE
Entity Type:Individual
Prefix:MISS
First Name:JASMINE
Middle Name:
Last Name:KORDBACHEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6699 W BOYNTON BEACH BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-3527
Mailing Address - Country:US
Mailing Address - Phone:561-296-1188
Mailing Address - Fax:
Practice Address - Street 1:6699 W BOYNTON BEACH BLVD STE B
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3527
Practice Address - Country:US
Practice Address - Phone:561-296-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
FLPA9109934363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical