Healthcare Provider Details

I. General information

NPI: 1356634539
Provider Name (Legal Business Name): JENNIFER MARIE HEAVEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 ALEXANDER ST
ROCHESTER NY
14607-2515
US

IV. Provider business mailing address

125 LATTIMORE RD SUITE 258
ROCHESTER NY
14620-4159
US

V. Phone/Fax

Practice location:
  • Phone: 585-545-1749
  • Fax:
Mailing address:
  • Phone: 585-442-8020
  • Fax: 585-442-8039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number336750
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: