Provider Demographics
NPI:1609218049
Name:COLBERT, JASMINE RALYNN
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:RALYNN
Last Name:COLBERT
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 1:3501 E GORE BLVD # 133
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-9813
Mailing Address - Country:US
Mailing Address - Phone:918-752-4790
Mailing Address - Fax:
Practice Address - Street 1:3501 E GORE BLVD # 133
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-9813
Practice Address - Country:US
Practice Address - Phone:918-752-4790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor