Provider Demographics
NPI:1013177658
Name:HEETDERKS, JENNIFER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:HEETDERKS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 CAMPUS RD
Mailing Address - Street 2:EMMONS HEALTH CENTER
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-3314
Mailing Address - Country:US
Mailing Address - Phone:323-259-2657
Mailing Address - Fax:
Practice Address - Street 1:1600 CAMPUS RD
Practice Address - Street 2:EMMONS HEALTH CENTER
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-3314
Practice Address - Country:US
Practice Address - Phone:323-259-2657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22924103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical