Provider Demographics
NPI:1508356361
Name:HEATON, JESSE C (DPT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:C
Last Name:HEATON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 3RD ST N STE 105
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5444
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:888-425-0398
Practice Address - Street 1:9242 HUDSON BLVD N STE 400
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8701
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:888-425-0398
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MN11083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist