Healthcare Provider Details

I. General information

NPI: 1508272857
Provider Name (Legal Business Name): JASON R HECKMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 POE AVE
DAYTON OH
45414-3440
US

IV. Provider business mailing address

5600 POE AVE
DAYTON OH
45414-3440
US

V. Phone/Fax

Practice location:
  • Phone: 937-458-0322
  • Fax: 937-401-1021
Mailing address:
  • Phone: 937-458-0322
  • Fax: 937-401-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number29800060
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: