Healthcare Provider Details

I. General information

NPI: 1689679474
Provider Name (Legal Business Name): JEFFREY D HEADDY RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/02/2024
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 S WALKER ST STE A
BLOOMINGTON IN
47403-2124
US

IV. Provider business mailing address

512 TIMBER RIDGE RD
SPENCER IN
47460-5981
US

V. Phone/Fax

Practice location:
  • Phone: 317-455-1064
  • Fax: 317-455-1204
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05004322A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: