Provider Demographics
NPI:1891009882
Name:JACKSON, HEATHER VANCE (MSW)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:VANCE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 WEATHERBY DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-9113
Mailing Address - Country:US
Mailing Address - Phone:307-633-7293
Mailing Address - Fax:
Practice Address - Street 1:2600 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5511
Practice Address - Country:US
Practice Address - Phone:307-633-7293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator