Provider Demographics
NPI:1043296742
Name:STASSART, JACQUES P
Entity Type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:P
Last Name:STASSART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 WOODWINDS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2525
Mailing Address - Country:US
Mailing Address - Phone:651-222-6050
Mailing Address - Fax:651-222-5975
Practice Address - Street 1:2101 WOODWINDS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2525
Practice Address - Country:US
Practice Address - Phone:651-222-6050
Practice Address - Fax:651-222-5975
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31216174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA96184Medicare UPIN