Provider Demographics
NPI:1003385436
Name:HEIL, JENNA ANNE (BA, AAC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ANNE
Last Name:HEIL
Suffix:
Gender:F
Credentials:BA, AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-0565
Mailing Address - Country:US
Mailing Address - Phone:360-385-0321
Mailing Address - Fax:
Practice Address - Street 1:884 W PARK AVE
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2273
Practice Address - Country:US
Practice Address - Phone:360-385-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60668080175T00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60668080Medicaid