Provider Demographics
NPI:1730480831
Name:FASULO, JENNIFER MARY (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARY
Last Name:FASULO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E 15TH ALY
Mailing Address - Street 2:APT 3
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4580
Mailing Address - Country:US
Mailing Address - Phone:203-228-0805
Mailing Address - Fax:
Practice Address - Street 1:3734 SE 15TH AVE
Practice Address - Street 2:APT 1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3857
Practice Address - Country:US
Practice Address - Phone:203-228-0805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201243142RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse