Provider Demographics
NPI:1659955425
Name:THOMAS, JASMINE TERELL (CEO)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:TERELL
Last Name:THOMAS
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8137 MONTAGE AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-4242
Mailing Address - Country:US
Mailing Address - Phone:317-654-2097
Mailing Address - Fax:
Practice Address - Street 1:8137 MONTAGE AVE APT 203
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-4242
Practice Address - Country:US
Practice Address - Phone:317-654-2097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0801856376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty