Healthcare Provider Details

I. General information

NPI: 1659517589
Provider Name (Legal Business Name): JEFFERY W HEATH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2008
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 N COUNTY ROAD 25A
TROY OH
45373-1337
US

IV. Provider business mailing address

3130 N COUNTY ROAD 25A
TROY OH
45373-1337
US

V. Phone/Fax

Practice location:
  • Phone: 937-440-7626
  • Fax: 937-440-7702
Mailing address:
  • Phone: 937-440-7626
  • Fax: 937-440-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE0003268SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: