Healthcare Provider Details

I. General information

NPI: 1013201961
Provider Name (Legal Business Name): JESSE INDERLEE LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13895 INDUSTRIAL PARK BLVD
PLYMOUTH MN
55441-3700
US

IV. Provider business mailing address

13895 INDUSTRIAL PARK BLVD
PLYMOUTH MN
55441-3700
US

V. Phone/Fax

Practice location:
  • Phone: 763-559-5677
  • Fax:
Mailing address:
  • Phone: 763-559-5677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number301412
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: