Provider Demographics
NPI:1598795734
Name:HEEREN, JONATHAN KEITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:KEITH
Last Name:HEEREN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BUCKSPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04416-4612
Mailing Address - Country:US
Mailing Address - Phone:207-469-7371
Mailing Address - Fax:
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-7556
Practice Address - Fax:207-973-7674
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME 726103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEOTH000Medicare UPIN
MEME1151Medicare ID - Type Unspecified