=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508942954
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEIDI A JACKSON ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 261 N ROOSEVELT AVE
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85226-2616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-305-2888
-----------------------------------------------------
Fax | 480-305-2889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 158 N MAIN ST PO BOX 299
-----------------------------------------------------
City | FLORIDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10921-1133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-651-1400
-----------------------------------------------------
Fax | 845-651-1510
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F332937
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------