Provider Demographics
NPI:1013201961
Name:INDERLEE, JESSE (LADC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:INDERLEE
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13895 INDUSTRIAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3700
Mailing Address - Country:US
Mailing Address - Phone:763-559-5677
Mailing Address - Fax:
Practice Address - Street 1:13895 INDUSTRIAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3700
Practice Address - Country:US
Practice Address - Phone:763-559-5677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301412101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)