Provider Demographics
NPI:1881096873
Name:HETELLE, JASON (MS, CF-SLP)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:HETELLE
Suffix:
Gender:M
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1335
Mailing Address - Country:US
Mailing Address - Phone:920-648-8344
Mailing Address - Fax:
Practice Address - Street 1:901 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1335
Practice Address - Country:US
Practice Address - Phone:920-648-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4027-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist