MEDICARE: DR. JESSICA BLAIR HETRICK-CANO PSYD, MSCP

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	103G00000X	Clinical Neuropsychologist	4106	CO
2	103TC0700X	Clinical Psychologist	1577	HI
3	103TC1900X	Counseling Psychologist	4106	CO
4	103TC0700X	Clinical Psychologist	4106	CO
5	103TC2200X	Clinical Child & Adolescent Psychologist	4106	CO
6	103TH0004X	Health Psychologist	4106	CO
7	103TM1800X	Intellectual & Developmental Disabilities Psychologist	4106	CO
8	103TR0400X	Rehabilitation Psychologist	4106	CO
9	103T00000X	Psychologist	4106	CO

General Provider Information

NPI Number	:	1730444142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA BLAIR HETRICK-CANO PSYD, MSCP

Provider Business Mailing Address
First Line	:	2918 BEACON ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-9208
Country	:	US
Telephone Number	:	719-964-8953
Fax Number	:	719-309-5864

Provider Business Practice Location Address
First Line	:	2918 BEACON ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-9208
Country	:	US
Telephone Number	:	719-964-8953
Fax Number	:	719-309-5864

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

Provider Enumeration Date	:	07/11/2012
Last Update Date	:	04/30/2021

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