Provider Demographics
NPI:1609044585
Name:HERZOG, JESSICA LEIGH (DPM)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LEIGH
Last Name:HERZOG
Suffix:
Gender:F
Credentials:DPM
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 639
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-0639
Mailing Address - Country:US
Mailing Address - Phone:303-814-1082
Mailing Address - Fax:
Practice Address - Street 1:2352 MEADOWS BLVD STE 270
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109
Practice Address - Country:US
Practice Address - Phone:303-814-1082
Practice Address - Fax:303-814-0020
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO73308213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18080073Medicaid