Provider Demographics
NPI:1265297501
Name:VAN TASSEL, JEREMY SHANE (LADC)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:SHANE
Last Name:VAN TASSEL
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 1:343 WOODLAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-6242
Mailing Address - Country:US
Mailing Address - Phone:507-289-2089
Mailing Address - Fax:
Practice Address - Street 1:1112 7TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1732
Practice Address - Country:US
Practice Address - Phone:507-289-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306946101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)