Healthcare Provider Details

I. General information

NPI: 1528794203
Provider Name (Legal Business Name): OTHER HEART, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 E SIERRA MADRE AVE
GILBERT AZ
85296-1970
US

IV. Provider business mailing address

3450 E SIERRA MADRE AVE
GILBERT AZ
85296-1970
US

V. Phone/Fax

Practice location:
  • Phone: 480-582-0344
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JAMIE JEFFERY
Title or Position: OWNER
Credential: LPC
Phone: 480-228-2419