Provider Demographics
NPI:1043796295
Name:FASSE, JONATHAN S
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:S
Last Name:FASSE
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 1:2340 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-5702
Mailing Address - Country:US
Mailing Address - Phone:515-263-0019
Mailing Address - Fax:
Practice Address - Street 1:2340 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5702
Practice Address - Country:US
Practice Address - Phone:515-263-0019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker