Provider Demographics
NPI:1467486340
Name:JACKSON, HEIDI (PA)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:SUNDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1847
Mailing Address - Country:US
Mailing Address - Phone:231-727-4444
Mailing Address - Fax:231-727-4451
Practice Address - Street 1:1700 CLINTON ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5502
Practice Address - Country:US
Practice Address - Phone:231-728-5692
Practice Address - Fax:231-728-4017
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004005363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1763007OtherMEDICARE