Provider Demographics
NPI:1497253512
Name:HEAGS, JIMMIE LEE JR
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:LEE
Last Name:HEAGS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JIMMIE
Other - Middle Name:LEE
Other - Last Name:HEAGS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:LPCC
Mailing Address - Street 1:5901 BROOKLYN BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2533
Mailing Address - Country:US
Mailing Address - Phone:612-440-0914
Mailing Address - Fax:
Practice Address - Street 1:5901 BROOKLYN BLVD STE 205
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-2533
Practice Address - Country:US
Practice Address - Phone:612-440-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN858101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional