Provider Demographics
NPI:1952173551
Name:HEAVLIN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HEAVLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:TAPIA
Other - Last Name:ALVAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47825 OASIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6950
Mailing Address - Country:US
Mailing Address - Phone:760-863-8623
Mailing Address - Fax:760-863-8353
Practice Address - Street 1:47825 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6950
Practice Address - Country:US
Practice Address - Phone:760-863-8623
Practice Address - Fax:760-863-8353
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist