Provider Demographics
NPI:1336288281
Name:JERSAK, HEATHER (SLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JERSAK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 SAN JACINTO AVE NE
Mailing Address - Street 2:MCCOLLUM ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-5414
Mailing Address - Country:US
Mailing Address - Phone:505-298-5009
Mailing Address - Fax:
Practice Address - Street 1:10900 SAN JACINTO AVE NE
Practice Address - Street 2:MCCOLLUM ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5414
Practice Address - Country:US
Practice Address - Phone:505-298-5009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3994235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM94839557Medicaid