Healthcare Provider Details

I. General information

NPI: 1104549419
Provider Name (Legal Business Name): TORI LAUREN HEISSE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TORI LAUREN EVANS MSW LSW

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 REYKO RD STE 100
JACKSONVILLE FL
32207-2828
US

IV. Provider business mailing address

2055 REYKO RD STE 100
JACKSONVILLE FL
32207-2828
US

V. Phone/Fax

Practice location:
  • Phone: 904-648-8200
  • Fax: 904-253-3270
Mailing address:
  • Phone: 904-648-8200
  • Fax: 904-253-3270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW26788
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.2208472
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: