Healthcare Provider Details

I. General information

NPI: 1407743891
Provider Name (Legal Business Name): JESSE HEADAPOHL FATOMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11770 W DAVIS LN
AVONDALE AZ
85323-7695
US

IV. Provider business mailing address

11770 W DAVIS LN
AVONDALE AZ
85323-7695
US

V. Phone/Fax

Practice location:
  • Phone: 480-217-8964
  • Fax:
Mailing address:
  • Phone: 480-217-8964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number326908
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN204116
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: