Provider Demographics
NPI:1366121964
Name:MCKOY, JASMINE T
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:T
Last Name:MCKOY
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 1:3507 KELBURN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-2094
Mailing Address - Country:US
Mailing Address - Phone:910-605-8107
Mailing Address - Fax:
Practice Address - Street 1:3507 KELBURN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-2094
Practice Address - Country:US
Practice Address - Phone:910-605-8107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management