Provider Demographics
NPI:1245205665
Name:HEATON, JANEIL M (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JANEIL
Middle Name:M
Last Name:HEATON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N WHITLEY DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2705
Mailing Address - Country:US
Mailing Address - Phone:208-452-6366
Mailing Address - Fax:208-452-6399
Practice Address - Street 1:215 N WHITLEY DR
Practice Address - Street 2:SUITE 1
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2705
Practice Address - Country:US
Practice Address - Phone:208-452-6366
Practice Address - Fax:208-452-6399
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1882174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806985500Medicaid
ID806985500Medicaid