Provider Demographics
NPI:1568670107
Name:HETZLER, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HETZLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 8TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HAZEN
Mailing Address - State:ND
Mailing Address - Zip Code:58545-4637
Mailing Address - Country:US
Mailing Address - Phone:701-748-2225
Mailing Address - Fax:701-748-5757
Practice Address - Street 1:510 8TH AVE NE
Practice Address - Street 2:
Practice Address - City:HAZEN
Practice Address - State:ND
Practice Address - Zip Code:58545-4637
Practice Address - Country:US
Practice Address - Phone:701-748-2225
Practice Address - Fax:701-748-5757
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25576OtherBCBS NUMBER