Provider Demographics
NPI:1689679474
Name:HEADDY, JEFFREY D (RPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:HEADDY
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 W BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5407
Mailing Address - Country:US
Mailing Address - Phone:317-455-1064
Mailing Address - Fax:317-455-1204
Practice Address - Street 1:639 S WALKER ST STE A
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2124
Practice Address - Country:US
Practice Address - Phone:317-455-1064
Practice Address - Fax:317-455-1204
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004322A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200488270Medicaid
IN200488270Medicaid