Healthcare Provider Details

I. General information

NPI: 1811795958
Provider Name (Legal Business Name): JASMINE FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

IV. Provider business mailing address

PO BOX 370150
DECATUR GA
30037-0150
US

V. Phone/Fax

Practice location:
  • Phone: 706-596-5500
  • Fax:
Mailing address:
  • Phone: 470-377-3517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number978281
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberGAA-NP003412
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: