Provider Demographics
NPI:1083193783
Name:HEANEY, JESSICA LYNN (NP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:HEANEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54516 AVONDALE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-1073
Mailing Address - Country:US
Mailing Address - Phone:586-524-5801
Mailing Address - Fax:
Practice Address - Street 1:1217 KEARNEY ST STE 2
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3571
Practice Address - Country:US
Practice Address - Phone:810-990-8302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704271858163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse