Healthcare Provider Details

I. General information

NPI: 1235473265
Provider Name (Legal Business Name): JILL HEATER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N WYATT DR
TUCSON AZ
85712-6106
US

IV. Provider business mailing address

2702 NORTH 3RD STREET 4020
PHOENIX AZ
85004-4608
US

V. Phone/Fax

Practice location:
  • Phone: 520-324-5437
  • Fax:
Mailing address:
  • Phone: 602-323-3407
  • Fax: 602-323-3496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86002710
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: