Provider Demographics
NPI:1073906574
Name:WELLS, JASMINE RANAE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:RANAE
Last Name:WELLS
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 1:413 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:IL
Mailing Address - Zip Code:61427-8830
Mailing Address - Country:US
Mailing Address - Phone:309-338-6070
Mailing Address - Fax:
Practice Address - Street 1:413 N 9TH ST
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:IL
Practice Address - Zip Code:61427-8830
Practice Address - Country:US
Practice Address - Phone:309-338-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist