Individual
JESSE HEADAPOHL FATOMA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
11770 W DAVIS LN, AVONDALE, AZ 85323-7695
(480) 217-8964
Mailing address
11770 W DAVIS LN, AVONDALE, AZ 85323-7695
(480) 217-8964
Taxonomy
Speciality
Code
Description
License number
State
163WP0807X
Child & Adolescent Psychiatric/Mental Health Registered Nurse
Primary
RN204116
AZ
163WP0808X
Psychiatric/Mental Health Registered Nurse
RN204116
AZ
Other
Enumeration date
06/19/2025
Last updated
06/19/2025
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