Healthcare Provider Details

I. General information

NPI: 1093628208
Provider Name (Legal Business Name): JESSALYNN HIETPAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 E WASHINGTON ST STE 1A
APPLETON WI
54911-5447
US

IV. Provider business mailing address

2305 W CAPITOL DR
APPLETON WI
54914-6831
US

V. Phone/Fax

Practice location:
  • Phone: 920-419-7302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number163788-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: