1417640905 NPI number — JESSICA MARIE HEELIS

Table of content: JESSICA MARIE HEELIS (NPI 1417640905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417640905 NPI number — JESSICA MARIE HEELIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEELIS
Provider First Name:
JESSICA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417640905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1182 S 730 W # NA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAYSON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84651-3108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-602-9049
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 E 400 N STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84653-9365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-696-9779
Provider Business Practice Location Address Fax Number:
385-999-6822
Provider Enumeration Date:
05/31/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  14247224-2506 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)