Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Jesse Headapohl Fatoma

Individual provider Psychiatric/Mental Health Nurse Practitioner · NPI 1407743891

Jesse Headapohl Fatoma is a Nurse Practitioner in Avondale, Arizona. Qualified in 2025, 1 year ago. Works from 2 locations. Licensed in Arizona.

Years since qualifying
1
Licensed in
AZ
In the registry since
2025
Specialties on file
2
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Practice location Address checks out

11770 W Davis Ln
Avondale, AZ 85323-7695
Phone: (480) 217-8964
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Additional practice locations (1)

  • 11770 W Davis Ln, Avondale, AZ 85323-7695 — (480) 217-8964

Specialties & licences

Psychiatric/Mental Health Nurse Practitioner (primary) Taxonomy 363LP0808X · Licence 326908 (AZ)
Psychiatric/Mental Health Registered Nurse Taxonomy 163WP0808X · Licence RN204116 (AZ)

Record details

NPI number1407743891
Entity typeIndividual (Type 1)
GenderMale
Sole proprietorNo
NPI enumeratedJune 19, 2025
Last updated in NPPESJune 5, 2026
Certification dateJune 5, 2026
Mailing address11770 W Davis Ln, Avondale, AZ 85323-7695

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyNURSE PRACTITIONER
Medical schoolOTHER
Graduated 2025 (1 years in practice)
Accepts Medicare assignment Not indicated
Practice locations2 on file with Medicare

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