Provider Demographics
NPI:1326058934
Name:HEATH, JENNIFER C (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:HEATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2710
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019
Mailing Address - Country:US
Mailing Address - Phone:972-258-9570
Mailing Address - Fax:972-258-9569
Practice Address - Street 1:6410 SOUTHWEST BLVD #101
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109
Practice Address - Country:US
Practice Address - Phone:817-735-1888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ69982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX260035942OtherMEDICARE RAILROAD
TX0098BWOtherBLUE CROSS BLUE SHIELD
TX113817401Medicaid
TX0098BWMedicare PIN
TX0098BWOtherBLUE CROSS BLUE SHIELD