MEDICARE: JESSE HEADAPOHL FATOMA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	326908	AZ
2	163WP0808X	Psychiatric/Mental Health Registered Nurse	RN204116	AZ

General Provider Information

NPI Number	:	1407743891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE HEADAPOHL FATOMA

Provider Business Mailing Address
First Line	:	11770 W DAVIS LN
Second Line	:
City	:	AVONDALE
State	:	AZ
Zip	:	85323-7695
Country	:	US
Telephone Number	:	480-217-8964
Fax Number	:

Provider Business Practice Location Address
First Line	:	11770 W DAVIS LN
Second Line	:
City	:	AVONDALE
State	:	AZ
Zip	:	85323-7695
Country	:	US
Telephone Number	:	480-217-8964
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2025
Last Update Date	:	06/05/2026

Similar Medicare Providers

1609719657 — JANGAY PSYCHIATRIC SERVICES
Practice Location Address:

11770 W DAVIS LN
AVONDALE, AZ
85323-7695

Practice Phone: 480-217-8964
Practice Fax:

1508798687 — TAMARA SAINZ
Practice Location Address:

200 N DYSART RD
AVONDALE, AZ
85323-2418

Practice Phone: 866-727-8274
Practice Fax:

1467385088 — ZACONA MICHAUX LAC
Practice Location Address:

506 E WESTERN AVE STE 104
AVONDALE, AZ
85323-2422

Practice Phone: 602-230-7373
Practice Fax: 602-682-7455

1821921354 — MR. DANIEL WILLIAMS LAC
Practice Location Address:

506 E WESTERN AVE STE 104
AVONDALE, AZ
85323-2422

Practice Phone: 602-230-7373
Practice Fax: 623-230-3086

1194728485 — DR. BETH ANN PYLE-SMITH O.D.
Practice Location Address:

13065 W MCDOWELL RD , STE B105
AVONDALE, AZ
85323-6442

Practice Phone: 623-845-1400
Practice Fax: 623-845-1401

1144226747 — AVONDALE ACCIDENT & PAIN CHIROPRACTIC CENTER
Practice Location Address:

11335 W BUCKEYE RD , STE C104
AVONDALE, AZ
85323-6814

Practice Phone: 623-936-6111
Practice Fax: 623-936-1629

Directions to “ JESSE HEADAPOHL FATOMA ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.