Provider Demographics
NPI:1215550470
Name:NYSTROM, JASMINA JOAN
Entity Type:Individual
Prefix:
First Name:JASMINA
Middle Name:JOAN
Last Name:NYSTROM
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 1:5457 SOUTHGATE BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-3447
Mailing Address - Country:US
Mailing Address - Phone:941-815-2859
Mailing Address - Fax:
Practice Address - Street 1:6570 SOSNA DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2222
Practice Address - Country:US
Practice Address - Phone:513-942-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician