Provider Demographics
NPI:1609111749
Name:HEARD, JESSE WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:WAYNE
Last Name:HEARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 AUGUSTA CHATHAM RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KY
Mailing Address - Zip Code:41002-9224
Mailing Address - Country:US
Mailing Address - Phone:606-756-2117
Mailing Address - Fax:
Practice Address - Street 1:1551 AUGUSTA CHATHAM RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KY
Practice Address - Zip Code:41002-9224
Practice Address - Country:US
Practice Address - Phone:606-756-2117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-30
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57417207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301101836OtherMICHIGAN EDUCATIONAL MEDICAL LICENSE
MIAS3062508-165OtherDEA