Provider Demographics
NPI:1962459941
Name:HEISER, JACQUELINE L (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
Last Name:HEISER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 PARKS HALL
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1359
Mailing Address - Country:US
Mailing Address - Phone:740-593-4609
Mailing Address - Fax:740-593-4166
Practice Address - Street 1:265 W UNION ST STE A
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2313
Practice Address - Country:US
Practice Address - Phone:740-594-2456
Practice Address - Fax:740-594-9630
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-007066207P00000X
WV1914207P00000X
OH34.007066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310917085094OtherCARESOURCE MEDICAID
OH000000181876OtherUNISON MEDICAID
080160257OtherRR MEDICARE
OH2133702OtherMOLINA MEDICAID
OH2133702Medicaid
000000196979OtherANTHEM BCBS
WV5600439000Medicaid
OH000000181876OtherUNISON MEDICAID
OH2133702OtherMOLINA MEDICAID
OH0890114Medicare PIN
080160257OtherRR MEDICARE