Provider Demographics
NPI:1720089865
Name:HEINKE, JESSICA DIXON (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:DIXON
Last Name:HEINKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3399
Mailing Address - Country:US
Mailing Address - Phone:815-338-0674
Mailing Address - Fax:815-338-6139
Practice Address - Street 1:233 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3399
Practice Address - Country:US
Practice Address - Phone:815-338-0674
Practice Address - Fax:815-338-6139
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009519152W00000X, 152WP0200X
SC1173152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5632090OtherIL BCBS
IL7333267OtherAETNA
IL5632090OtherIL BCBS
ILU81683Medicare UPIN