Basic Information
| Provider Information | |||||||||
| NPI: | 1417162694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEMAN | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3225 INDEPENDENCE RD | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812129380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192752351 | ||||||||
| FaxNumber: | 7192699386 | ||||||||
| Practice Location | |||||||||
| Address1: | 511 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WESTCLIFFE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812528309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197830566 | ||||||||
| FaxNumber: | 7197920107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 04204875 | 05 | CO | MEDICAID |