Provider Demographics
NPI:1104865955
Name:HEAVEN, JORDANA A (MD)
Entity Type:Individual
Prefix:
First Name:JORDANA
Middle Name:A
Last Name:HEAVEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JORDANA
Other - Middle Name:
Other - Last Name:APOSTOLICO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2000 PROFESSIONAL WAY
Mailing Address - Street 2:BLDG 200
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188
Mailing Address - Country:US
Mailing Address - Phone:770-517-0250
Mailing Address - Fax:770-517-0260
Practice Address - Street 1:2000 PROFESSIONAL WAY
Practice Address - Street 2:STE 200
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188
Practice Address - Country:US
Practice Address - Phone:770-517-0250
Practice Address - Fax:770-517-0260
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049697208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics