=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306520861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA HEJKA MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2023
-----------------------------------------------------
Last Update Date | 06/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 454 S HARVEY ST
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48170-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-416-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6603 BROOKSHIRE DR
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48187-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-674-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | PP0000001101722
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------