Provider Demographics
NPI:1770852170
Name:HEATON, JESSICA L (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:HEATON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:KIRKPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:560 S LOOP RD STE 500
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-817-7848
Practice Address - Street 1:4355 FERGUSON DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-5136
Practice Address - Country:US
Practice Address - Phone:513-232-2663
Practice Address - Fax:859-817-7848
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004192363A00000X
OH50.003745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086829Medicaid
H195640Medicare PIN