# ACTIVE KETAMINE, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1073259156
- **Authorized official:** JARED HEATHMAN (MANAGING MEMBER)
- **Authorized official phone:** (281) 201-4511

## Contact information

- **Practice address:** 12250 QUEENSTON BLVD STE E, HOUSTON, TX 77095-5343
- **Practice address phone:** (281) 201-4511
- **Mailing address:** 12250 QUEENSTON BLVD STE E, HOUSTON, TX 77095-5343

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2084P2900X | Pain Medicine (Psychiatry & Neurology) Physician | — | NULL | Yes |
| 2084P2900X | Pain Medicine (Psychiatry & Neurology) Physician | — | — | Yes |

## Other

- **Enumeration date:** 05/11/2022
- **Last updated:** 05/11/2022