Provider Demographics
NPI:1407743891
Name:FATOMA, JESSE HEADAPOHL
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:HEADAPOHL
Last Name:FATOMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11770 W DAVIS LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-7695
Mailing Address - Country:US
Mailing Address - Phone:480-217-8964
Mailing Address - Fax:
Practice Address - Street 1:11770 W DAVIS LN
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-7695
Practice Address - Country:US
Practice Address - Phone:480-217-8964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN204116163WP0808X, 163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health