Provider Demographics
NPI:1649838780
Name:JASSO, NICOLE LYNN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:JASSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:EGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2526
Mailing Address - Country:US
Mailing Address - Phone:417-347-7579
Mailing Address - Fax:
Practice Address - Street 1:3010 MCCLELLAND
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-347-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200124541041C0700X
171M00000X
MO20220286621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator