Basic Information
| Provider Information | |||||||||
| NPI: | 1326058934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEATH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2710 | ||||||||
| Address2: | |||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722589570 | ||||||||
| FaxNumber: | 9722589569 | ||||||||
| Practice Location | |||||||||
| Address1: | 6410 SOUTHWEST BLVD #101 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177351888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | J6998 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 260035942 | 01 | TX | MEDICARE RAILROAD | OTHER | 0098BW | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 113817401 | 05 | TX | MEDICAID |