Provider Demographics
NPI:1871749846
Name:HEINTZ-JACOBS, GG (MA)
Entity type:Individual
Prefix:MRS
First Name:GG
Middle Name:
Last Name:HEINTZ-JACOBS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 E BROADWAY RD
Mailing Address - Street 2:#231
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-1751
Mailing Address - Country:US
Mailing Address - Phone:310-210-3121
Mailing Address - Fax:
Practice Address - Street 1:2940 E BROADWAY RD
Practice Address - Street 2:#231
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-1751
Practice Address - Country:US
Practice Address - Phone:310-210-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4069454103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool