Provider Demographics
NPI:1649933466
Name:HEIMKE, JESSICA TAYLOR (SLP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:TAYLOR
Last Name:HEIMKE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W3095 ELMORE DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010-2522
Mailing Address - Country:US
Mailing Address - Phone:262-339-4696
Mailing Address - Fax:
Practice Address - Street 1:6700 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3998
Practice Address - Country:US
Practice Address - Phone:414-351-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5384-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist