Provider Demographics
NPI:1316054422
Name:HESTON, JERRY D (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:HESTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:DEPT 233
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-758-1980
Mailing Address - Fax:901-309-8784
Practice Address - Street 1:1135 CULLY RD
Practice Address - Street 2:STE 100
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-8503
Practice Address - Country:US
Practice Address - Phone:901-758-1980
Practice Address - Fax:901-309-8784
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0149922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3015362Medicaid
TN3015362Medicaid
3015362Medicare ID - Type Unspecified