Provider Demographics
NPI:1073361606
Name:HEISE, JONATHAN EDWARD (MA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:EDWARD
Last Name:HEISE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 DAWES AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6308
Mailing Address - Country:US
Mailing Address - Phone:630-743-3417
Mailing Address - Fax:
Practice Address - Street 1:1616 E ROOSEVELT RD STE 8
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-6850
Practice Address - Country:US
Practice Address - Phone:630-588-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health