Provider Demographics
NPI:1235746892
Name:SCOTT, JASMINE DANAE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:DANAE
Last Name:SCOTT
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 1:105 SOUTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-3761
Mailing Address - Country:US
Mailing Address - Phone:832-986-3611
Mailing Address - Fax:
Practice Address - Street 1:11531 SUNDERLAND RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8274
Practice Address - Country:US
Practice Address - Phone:832-986-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.129467164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse