Provider Demographics
NPI:1770641250
Name:JACKMAN, HEATHER (MA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 W CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3014
Mailing Address - Country:US
Mailing Address - Phone:224-735-3484
Mailing Address - Fax:
Practice Address - Street 1:902 W CYPRESS DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-3014
Practice Address - Country:US
Practice Address - Phone:630-723-7216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2684-154235Z00000X
IL146-006776235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42569700Medicaid