Provider Demographics
NPI:1578806618
Name:HEINTZELMAN, JESSICA L (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:HEINTZELMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:2995 REIDVILLE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5628
Practice Address - Country:US
Practice Address - Phone:864-253-8140
Practice Address - Fax:864-587-0051
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC39084AMedicaid
SCSC88755019OtherMEDICARE PIN