Provider Demographics
NPI:1912152463
Name:HETTENBAUGH, JAYNE MARIE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:MARIE
Last Name:HETTENBAUGH
Suffix:
Gender:F
Credentials:MA 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:P.O.BOX 53
Mailing Address - Street 2:126 LARKIN STREET
Mailing Address - City:RANDOLPH
Mailing Address - State:NY
Mailing Address - Zip Code:14772-0053
Mailing Address - Country:US
Mailing Address - Phone:716-358-9236
Mailing Address - Fax:
Practice Address - Street 1:126 LARKIN STREET EXT
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NY
Practice Address - Zip Code:14772-9651
Practice Address - Country:US
Practice Address - Phone:716-358-9236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007795-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist