Provider Demographics
NPI:1679047625
Name:GOLDMAN, JASMINE R (NCC, LPCA)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:R
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:NCC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10816 TWISTED BARK LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 E 6TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2918
Practice Address - Country:US
Practice Address - Phone:704-975-8918
Practice Address - Fax:704-731-0980
Is Sole Proprietor?:No
Enumeration Date:2019-01-13
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1175831101YS0200X
NCA13959101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool