Provider Demographics
NPI:1669685004
Name:HETRICK, JENNIFER ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELLEN
Last Name:HETRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6695 THORNE ST
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2431
Mailing Address - Country:US
Mailing Address - Phone:646-831-8044
Mailing Address - Fax:614-957-8610
Practice Address - Street 1:885 HIGH ST STE 107
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-4158
Practice Address - Country:US
Practice Address - Phone:614-368-7070
Practice Address - Fax:614-957-8610
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD108705207Q00000X
NY260281207Q00000X
OH35. 089073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0184211Medicaid