Provider Demographics
NPI:1295221224
Name:FULLER, JASMINE T (LPN)
Entity Type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:T
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:JASMINE
Other - Middle Name:T
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:400 BOWMAN ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-1235
Mailing Address - Country:US
Mailing Address - Phone:419-525-3525
Mailing Address - Fax:
Practice Address - Street 1:400 BOWMAN ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-1235
Practice Address - Country:US
Practice Address - Phone:419-525-3525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.163763.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse