MEDICARE: JEFFERY L HETRICK MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	M-06487	NM

General Provider Information

NPI Number	:	1255560330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFERY L HETRICK MSW

Provider Business Mailing Address
First Line	:	1980 E LOHMAN AVE
Second Line	:	SUITE B
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-3194
Country	:	US
Telephone Number	:	575-526-9900
Fax Number	:	575-523-8640

Provider Business Practice Location Address
First Line	:	1980 E LOHMAN AVE
Second Line	:	SUITE B
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-3194
Country	:	US
Telephone Number	:	575-526-9900
Fax Number	:	575-523-8640

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2009
Last Update Date	:	07/09/2009

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