Provider Demographics
NPI:1598890964
Name:JANSEN, HEIDI NICOLE (MS)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:NICOLE
Last Name:JANSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12319 WOODBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4191
Mailing Address - Country:US
Mailing Address - Phone:501-312-0479
Mailing Address - Fax:
Practice Address - Street 1:1500 WILSON LOOP
Practice Address - Street 2:
Practice Address - City:WARD
Practice Address - State:AR
Practice Address - Zip Code:72176
Practice Address - Country:US
Practice Address - Phone:501-941-5630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1640235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5U635OtherBCBS #