Basic Information
| Provider Information | |||||||||
| NPI: | 1518318898 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HETTINGER | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 891 WESTMINSTER ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013317850 | ||||||||
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| Practice Location | |||||||||
| Address1: | 891 WESTMINSTER ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013317850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | ODTG00646 | RI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.