Provider Demographics
NPI:1255575353
Name:HETMAN, JESSICA LYNN (MSED)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:HETMAN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 TIPTON DR W
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3509
Mailing Address - Country:US
Mailing Address - Phone:631-657-3433
Mailing Address - Fax:631-657-3433
Practice Address - Street 1:42 TIPTON DR W
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-3509
Practice Address - Country:US
Practice Address - Phone:631-657-3433
Practice Address - Fax:631-657-3433
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1759381171M00000X
NY009487224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1759381OtherPRE-KINDERGARTEN, KINDERGARTEN & GRADES 1-6, PERMANENT
NY1759381OtherSTUDENTS WITH DISABILITIES (B-2)
NY1759381OtherSTUDENTS WITH DISABILITIES (1-6)