Provider Demographics
NPI:1699831214
Name:VAN TASSEL, JIMMY DEAN (LCSW)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:DEAN
Last Name:VAN TASSEL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 E ORANGEBURG AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3236
Mailing Address - Country:US
Mailing Address - Phone:209-544-6869
Mailing Address - Fax:
Practice Address - Street 1:1320 STANDIFORD AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0726
Practice Address - Country:US
Practice Address - Phone:209-557-5765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 178031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical