Provider Demographics
NPI:1083611735
Name:HIECKE, JENNIFER KAY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:KAY
Last Name:HIECKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 5TH AVE N STE 202
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1410
Mailing Address - Country:US
Mailing Address - Phone:727-820-7701
Mailing Address - Fax:727-820-7700
Practice Address - Street 1:1201 5TH AVE N
Practice Address - Street 2:SUITE 202
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1400
Practice Address - Country:US
Practice Address - Phone:727-820-7701
Practice Address - Fax:727-820-7700
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102321363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00733266OtherRAILROAD MEDICARE PROVIDER NUMBER
FL106274100Medicaid
P93484Medicare UPIN
FLU0988WMedicare PIN