Provider Demographics
NPI:1225104656
Name:HETTLER, JESSICA LAURA (DPT, ATC, CERT MDT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAURA
Last Name:HETTLER
Suffix:
Gender:F
Credentials:DPT, ATC, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ATLANTIC AVE
Mailing Address - Street 2:APT 401
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3511
Mailing Address - Country:US
Mailing Address - Phone:516-641-7364
Mailing Address - Fax:
Practice Address - Street 1:23 RHAME AVE
Practice Address - Street 2:
Practice Address - City:EAST ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11518-1445
Practice Address - Country:US
Practice Address - Phone:516-641-7364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026463174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ17Q11Medicare ID - Type UnspecifiedMEDICARE ID #