Healthcare Provider Details

I. General information

NPI: 1780064097
Provider Name (Legal Business Name): JACQUELYN HERON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 N UNION AVE
HAVRE DE GRACE MD
21078-2825
US

IV. Provider business mailing address

2612 TAPLIN LN
FALLSTON MD
21047-2048
US

V. Phone/Fax

Practice location:
  • Phone: 410-939-3121
  • Fax:
Mailing address:
  • Phone: 410-688-0034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR193492
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR193492
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: