Provider Demographics
NPI:1720553399
Name:TATUM, JASMIN DANIELLE
Entity Type:Individual
Prefix:
First Name:JASMIN
Middle Name:DANIELLE
Last Name:TATUM
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 1:407 E HOGAN DR
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-1836
Mailing Address - Country:US
Mailing Address - Phone:254-681-8264
Mailing Address - Fax:
Practice Address - Street 1:407 E HOGAN DR
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-1836
Practice Address - Country:US
Practice Address - Phone:254-681-8264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician