Provider Demographics
NPI:1679523674
Name:HEETHOUSE, JACK (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:HEETHOUSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MERCY DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MICHIGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49444
Mailing Address - Country:US
Mailing Address - Phone:231-733-1326
Mailing Address - Fax:231-733-5212
Practice Address - Street 1:1400 MERCY DR.
Practice Address - Street 2:SUITE 100
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:231-733-5212
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012999174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4308380Medicaid
MI4308380Medicaid
MIH40569Medicare UPIN