Provider Demographics
NPI:1124455183
Name:JERZAK, HEATHER (RD, CD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JERZAK
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6520 LUMBERJACK GUY RD
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-5405
Mailing Address - Country:US
Mailing Address - Phone:715-284-9851
Mailing Address - Fax:715-284-5150
Practice Address - Street 1:N6520 LUMBER JACK GUY RD
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615
Practice Address - Country:US
Practice Address - Phone:888-685-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2652-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered