Provider Demographics
NPI:1093241564
Name:VASSEL, JAQUAN (CPED, BOCPD)
Entity Type:Individual
Prefix:
First Name:JAQUAN
Middle Name:
Last Name:VASSEL
Suffix:
Gender:M
Credentials:CPED, BOCPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7150 NATURAL BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-5151
Mailing Address - Country:US
Mailing Address - Phone:314-381-8600
Mailing Address - Fax:314-381-6844
Practice Address - Street 1:7150 NATURAL BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-5151
Practice Address - Country:US
Practice Address - Phone:314-381-8600
Practice Address - Fax:314-381-6844
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCPED4300224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist