Provider Demographics
NPI:1770996738
Name:HEACOCK, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HEACOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 HARDING WAY W
Mailing Address - Street 2:
Mailing Address - City:GALION
Mailing Address - State:OH
Mailing Address - Zip Code:44833-1729
Mailing Address - Country:US
Mailing Address - Phone:419-468-5340
Mailing Address - Fax:
Practice Address - Street 1:304 HARDING WAY W
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-1729
Practice Address - Country:US
Practice Address - Phone:419-468-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-07
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03232753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist