Basic Information
| Provider Information | |||||||||
| NPI: | 1962459941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEISER | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 126 PARKS HALL | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457011359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405934609 | ||||||||
| FaxNumber: | 7405934166 | ||||||||
| Practice Location | |||||||||
| Address1: | 265 W UNION ST STE A | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457012313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405942456 | ||||||||
| FaxNumber: | 7405949630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 06/01/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34-007066 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 1914 | WV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 34.007066 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 310917085094 | 01 | OH | CARESOURCE MEDICAID | OTHER | 000000181876 | 01 | OH | UNISON MEDICAID | OTHER | 080160257 | 01 | RR MEDICARE | OTHER | 2133702 | 01 | OH | MOLINA MEDICAID | OTHER | 2133702 | 05 | OH | MEDICAID | 000000196979 | 01 | ANTHEM BCBS | OTHER | 5600439000 | 05 | WV | MEDICAID |