Provider Demographics
NPI:1063781797
Name:HEAVENS, JASON PERNELL (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:PERNELL
Last Name:HEAVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:105 S DELAWARE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-6512
Mailing Address - Country:US
Mailing Address - Phone:480-646-1001
Mailing Address - Fax:480-646-1002
Practice Address - Street 1:9225 N 3RD ST STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2455
Practice Address - Country:US
Practice Address - Phone:602-362-2983
Practice Address - Fax:480-565-4552
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2021-02-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ44336207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine