Provider Demographics
NPI:1669090049
Name:JACKSON, HEATHER LEE (CNM, MSN)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:
Credentials:CNM, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6050 STERLING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-7752
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-5333
Practice Address - Street 1:6050 STERLING CREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-7752
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-764-5333
Is Sole Proprietor?:No
Enumeration Date:2020-07-11
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010201A367A00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife