Provider Demographics
NPI:1174614150
Name:KASL, JACK (PHD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:KASL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3095 NORWAY CIR S
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-2670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1790 11TH ST SE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1968
Practice Address - Country:US
Practice Address - Phone:612-867-8451
Practice Address - Fax:763-552-0787
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1955103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical