Provider Demographics
NPI:1467966978
Name:HEERSINK, JACKIE MICHELLE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:MICHELLE
Last Name:HEERSINK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4071 STAMPEDE DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-7849
Mailing Address - Country:US
Mailing Address - Phone:303-720-8955
Mailing Address - Fax:
Practice Address - Street 1:5825 DELMONICO DR STE 300
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2244
Practice Address - Country:US
Practice Address - Phone:719-577-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7225225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist