Healthcare Provider Details

I. General information

NPI: 1316802952
Provider Name (Legal Business Name): JESSE M SIMMONS TCDAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 17TH ST SE
CEDAR RAPIDS IA
52403-2610
US

IV. Provider business mailing address

54 OKLAHOMA AVE SW
CEDAR RAPIDS IA
52404-5327
US

V. Phone/Fax

Practice location:
  • Phone: 319-893-9621
  • Fax:
Mailing address:
  • Phone: 319-893-9621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: