Provider Demographics
NPI:1982194668
Name:HEICKLEN, JODIE REBECCA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JODIE
Middle Name:REBECCA
Last Name:HEICKLEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25507 HEREFORD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1639
Mailing Address - Country:US
Mailing Address - Phone:917-536-2330
Mailing Address - Fax:
Practice Address - Street 1:17344 W 12 MILE RD STE 207
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-6321
Practice Address - Country:US
Practice Address - Phone:917-536-2330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093976104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker