Provider Demographics
NPI:1770081002
Name:HERON, JESSICA ELEANOR (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELEANOR
Last Name:HERON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 E PARKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9352
Mailing Address - Country:US
Mailing Address - Phone:231-398-1760
Mailing Address - Fax:231-398-1768
Practice Address - Street 1:1391 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9352
Practice Address - Country:US
Practice Address - Phone:231-398-1760
Practice Address - Fax:231-398-1768
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601008552OtherMICHIGAN LICENSE