Provider Demographics
NPI:1447592563
Name:HEISEY, JENNIFER C (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:HEISEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:C
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1551 N WALNUT AVE STE 47
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-6045
Mailing Address - Country:US
Mailing Address - Phone:830-358-1151
Mailing Address - Fax:830-626-3422
Practice Address - Street 1:1551 N WALNUT AVE STE 47
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-6045
Practice Address - Country:US
Practice Address - Phone:830-358-1151
Practice Address - Fax:830-626-3422
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019764208100000X
TX1242810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070019764Medicaid