Provider Demographics
NPI:1851954622
Name:CLEVINGER, JASMINE DAWN
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:DAWN
Last Name:CLEVINGER
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:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-0358
Mailing Address - Country:US
Mailing Address - Phone:276-244-0784
Mailing Address - Fax:
Practice Address - Street 1:388 BEN BOLT AVE
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24651-5386
Practice Address - Country:US
Practice Address - Phone:276-988-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202217086183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist