=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225537251
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA HEATON MAMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2018
-----------------------------------------------------
Last Update Date | 02/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6122 RIDGE AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-420-2103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 MAPLEWOOD DR APT A
-----------------------------------------------------
City | MAPLE SHADE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08052-1971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-420-2103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------