Basic Information
| Provider Information | |||||||||
| NPI: | 1205190956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEERKENS | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSED | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EMPEY | ||||||||
| OtherFirstName: | JENNA | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSED | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6 N MAIN ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | FAIRPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144501524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853776590 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6 N MAIN ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | FAIRPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144501524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853776590 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2012 | ||||||||
| LastUpdateDate: | 06/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.