Provider Demographics
NPI:1851263321
Name:MARY, JASMIN
Entity type:Individual
Prefix:
First Name:JASMIN
Middle Name:
Last Name:MARY
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 1:6666 TORYBROOKE CIR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19000 ST JOES PKWY STE 140
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1477
Practice Address - Country:US
Practice Address - Phone:734-213-3688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704382277363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care