Provider Demographics
NPI:1134812530
Name:HEADLEE, JEREMY JACK (RN)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:JACK
Last Name:HEADLEE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 N LAKEVIEW CIR APT G
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-8841
Mailing Address - Country:US
Mailing Address - Phone:317-642-6097
Mailing Address - Fax:
Practice Address - Street 1:1220 N LAKEVIEW CIR APT G
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-8841
Practice Address - Country:US
Practice Address - Phone:317-642-6097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28214884A163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management