Provider Demographics
NPI:1275199895
Name:HELLER, JESSICA NICHOLE (MA, CCC-SLP, TSLD)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:NICHOLE
Last Name:HELLER
Suffix:
Gender:F
Credentials:MA, CCC-SLP, TSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WILD RUN
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-7522
Mailing Address - Country:US
Mailing Address - Phone:631-487-1505
Mailing Address - Fax:
Practice Address - Street 1:495 HOFFMAN LN STE 3
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3102
Practice Address - Country:US
Practice Address - Phone:631-650-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY030099235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program