Healthcare Provider Details

I. General information

NPI: 1679259147
Provider Name (Legal Business Name): JACK REED HECKL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 S. LOS ROBLES KAISER PERMANENTE BERNARD J. TYSON SCHOOL OF MEDICINE
PASADENA CA
91101
US

IV. Provider business mailing address

98 S. LOS ROBLES KAISER PERMANENTE BERNARD J. TYSON SCHOOL OF MEDICINE
PASADENA CA
91101
US

V. Phone/Fax

Practice location:
  • Phone: 888-576-3348
  • Fax:
Mailing address:
  • Phone: 888-576-3348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: