Provider Demographics
NPI:1275899189
Name:HEINEN, JEAN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:MARIE
Last Name:HEINEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JEAN
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:MS 958
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:4855 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:262-432-7599
Practice Address - Fax:262-432-7694
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61601208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275899189Medicaid
WIK400227609Medicare PIN