MEDICARE: HEIDI S JACKMAN BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	0000086388	NV

General Provider Information

NPI Number	:	1336431428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI S JACKMAN BA

Provider Business Mailing Address
First Line	:	895 ROBERTA LN
Second Line	:	SUITE 101
City	:	SPARKS
State	:	NV
Zip	:	89431-6802
Country	:	US
Telephone Number	:	775-331-6252
Fax Number	:	775-331-6250

Provider Business Practice Location Address
First Line	:	895 ROBERTA LN
Second Line	:	SUITE 101
City	:	SPARKS
State	:	NV
Zip	:	89431-6802
Country	:	US
Telephone Number	:	775-331-6252
Fax Number	:	775-331-6250

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2011
Last Update Date	:	05/06/2011

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Directions to “ HEIDI S JACKMAN BA” Practice Location

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