Provider Demographics
NPI:1992066625
Name:HEATON, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:HEATON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6818 CHANDON DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-6056
Mailing Address - Country:US
Mailing Address - Phone:402-617-0317
Mailing Address - Fax:
Practice Address - Street 1:300 N 44TH ST STE 105
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68503-3415
Practice Address - Country:US
Practice Address - Phone:402-617-0317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NE4845101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker