1588911317 NPI number — DR. HEATHER ANNE JACKSON-PENA OTD, MOT, OTR/L, ETS

Table of content: DR. HEATHER ANNE JACKSON-PENA OTD, MOT, OTR/L, ETS (NPI 1588911317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588911317 NPI number — DR. HEATHER ANNE JACKSON-PENA OTD, MOT, OTR/L, ETS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON-PENA
Provider First Name:
HEATHER
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OTD, MOT, OTR/L, ETS
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:
1588911317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
932 HUNGERFORD DR STE 9B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20850-1750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-535-4036
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
932 HUNGERFORD DR STE 9B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20850-1750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-535-4036
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2012

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: 225XP0200X , with the licence number:  05710 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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