Provider Demographics
NPI:1235473265
Name:HEATER, JILL (RD)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:
Last Name:HEATER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 NORTH 3RD STREET
Mailing Address - Street 2:4020
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4608
Mailing Address - Country:US
Mailing Address - Phone:602-323-3407
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:2600 N WYATT DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6106
Practice Address - Country:US
Practice Address - Phone:520-324-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86002710133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ756944Medicaid