Provider Demographics
NPI:1922661222
Name:HECKERT, JAY ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ROBERT
Last Name:HECKERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12140 NALL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2503
Mailing Address - Country:US
Mailing Address - Phone:973-498-7005
Mailing Address - Fax:913-498-6708
Practice Address - Street 1:2100 SE BLUE PARKWAY
Practice Address - Street 2:LEES SUMMIT MEDICAL CENTER
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063
Practice Address - Country:US
Practice Address - Phone:816-282-5000
Practice Address - Fax:913-498-6708
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS9410078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program