Provider Demographics
NPI:1780064097
Name:HERON, JACQUELYN
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:HERON
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 1:2612 TAPLIN LN
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:MD
Mailing Address - Zip Code:21047-2048
Mailing Address - Country:US
Mailing Address - Phone:410-688-0034
Mailing Address - Fax:
Practice Address - Street 1:308 N UNION AVE
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-2825
Practice Address - Country:US
Practice Address - Phone:410-939-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR193492163W00000X, 367A00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse