Provider Demographics
NPI:1508592197
Name:BERRY, HEATHER JO
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:JO
Last Name:BERRY
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 1:74 S 2ND ST
Mailing Address - Street 2:PO BOX 5030
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43058-5030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 S 2ND ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5415
Practice Address - Country:US
Practice Address - Phone:740-670-8975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2615030Medicaid