Provider Demographics
NPI:1083312615
Name:WICKS, JASMINE ROSE BULLOCK (CD(DONA))
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:ROSE BULLOCK
Last Name:WICKS
Suffix:
Gender:F
Credentials:CD(DONA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5486 LOETA WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99712-3531
Mailing Address - Country:US
Mailing Address - Phone:228-547-7832
Mailing Address - Fax:
Practice Address - Street 1:5486 LOETA WAY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712-3531
Practice Address - Country:US
Practice Address - Phone:228-547-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula