Provider Demographics
NPI:1770538480
Name:HEINEMANN, JENNIFER A (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:HEINEMANN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF PSYCHIATRY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3666
Mailing Address - Fax:414-955-6282
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF PSYCHIATRY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3666
Practice Address - Fax:414-955-6282
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2333-057103TH0004X
WI2333103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY39134400Medicaid
WIP43639Medicare UPIN
WI84013Medicare ID - Type UnspecifiedMEDICARE