Provider Demographics
NPI:1750699054
Name:JENNY, HEATHER SUE (PT)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:SUE
Last Name:JENNY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3344 PIAZZA LN
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3225
Mailing Address - Country:US
Mailing Address - Phone:402-680-9272
Mailing Address - Fax:
Practice Address - Street 1:3344 PIAZZA LN
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3225
Practice Address - Country:US
Practice Address - Phone:402-680-9272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-21
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251G0304X, 225100000X
NE9412251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025508900Medicaid
NE10025670600Medicaid
NE10025670600Medicaid