Provider Demographics
NPI:1013281773
Name:HEIDE, JESSICA (MPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HEIDE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 N TRAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:TX
Mailing Address - Zip Code:76520-1665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2202 N TRAVIS AVE
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:TX
Practice Address - Zip Code:76520-1665
Practice Address - Country:US
Practice Address - Phone:254-697-6564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1210043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist