Healthcare Provider Details

I. General information

NPI: 1629710017
Provider Name (Legal Business Name): JESSICA HEFFERNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1779 GREEN BAY RD STE 101
HIGHLAND PARK IL
60035-3118
US

IV. Provider business mailing address

1779 GREEN BAY RD STE 101
HIGHLAND PARK IL
60035-3118
US

V. Phone/Fax

Practice location:
  • Phone: 847-266-0131
  • Fax:
Mailing address:
  • Phone: 847-266-0131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.004553
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: