MEDICARE: JACKIE MICHELLE HEERSINK

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	225100000X	Physical Therapist	7225	CO

General Provider Information

NPI Number	:	1467966978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE MICHELLE HEERSINK

Provider Business Mailing Address
First Line	:	4071 STAMPEDE DR
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-7849
Country	:	US
Telephone Number	:	303-720-8955
Fax Number	:

Provider Business Practice Location Address
First Line	:	5825 DELMONICO DR STE 300
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-2244
Country	:	US
Telephone Number	:	719-577-4104
Fax Number	:

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

Provider Enumeration Date	:	11/20/2017
Last Update Date	:	11/20/2017

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Directions to “ JACKIE MICHELLE HEERSINK ” Practice Location

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