Provider Demographics
NPI:1275221582
Name:HEATON, JENICA
Entity Type:Individual
Prefix:
First Name:JENICA
Middle Name:
Last Name:HEATON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MAHOGANY AVE APT 217
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-8424
Mailing Address - Country:US
Mailing Address - Phone:435-496-3662
Mailing Address - Fax:
Practice Address - Street 1:4120 MERIDIAN ST STE 220
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-5575
Practice Address - Country:US
Practice Address - Phone:360-922-3030
Practice Address - Fax:360-306-8374
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator