Provider Demographics
NPI:1730102294
Name:HETHCOCK, JENNIFER MD (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MD
Last Name:HETHCOCK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6352 DARTMOUTH WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4608
Mailing Address - Country:US
Mailing Address - Phone:757-803-5327
Mailing Address - Fax:757-803-5327
Practice Address - Street 1:1853 OLD DONATION PKWY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3004
Practice Address - Country:US
Practice Address - Phone:757-421-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004790235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1231877OtherCAQH