Basic Information
| Provider Information | |||||||||
| NPI: | 1710403803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VASICHEK | ||||||||
| FirstName: | JASMINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 647 13TH AVE E STE A | ||||||||
| Address2: | |||||||||
| City: | WEST FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580783328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012778844 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2624 9TH AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012778844 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2017 | ||||||||
| LastUpdateDate: | 01/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 5817 | ND | N | Behavioral Health & Social Service Providers | Social Worker | 106S00000X | N | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.