Healthcare Provider Details

I. General information

NPI: 1275917296
Provider Name (Legal Business Name): JACK HEINEMANN LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 CEDAR LN STE 6
TEANECK NJ
07666-4315
US

IV. Provider business mailing address

175 CEDAR LN STE 6
TEANECK NJ
07666-4315
US

V. Phone/Fax

Practice location:
  • Phone: 718-413-2600
  • Fax:
Mailing address:
  • Phone: 646-501-3309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06030100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number087410
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: