Provider Demographics
NPI:1407359185
Name:SUCCES, JASMINE ELAINE (ATC)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:ELAINE
Last Name:SUCCES
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 N STATE HIGHWAY 360 APT 8303
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9039
Mailing Address - Country:US
Mailing Address - Phone:682-402-3672
Mailing Address - Fax:
Practice Address - Street 1:1000 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-4112
Practice Address - Country:US
Practice Address - Phone:682-402-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer