Provider Demographics
NPI:1730444142
Name:HETRICK-CANO, JESSICA BLAIR (PSYD, MSCP)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:BLAIR
Last Name:HETRICK-CANO
Suffix:
Gender:F
Credentials:PSYD, MSCP
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:BLAIR
Other - Last Name:CANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD, MSCP
Mailing Address - Street 1:2918 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-9208
Mailing Address - Country:US
Mailing Address - Phone:719-964-8953
Mailing Address - Fax:719-309-5864
Practice Address - Street 1:2918 BEACON ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-9208
Practice Address - Country:US
Practice Address - Phone:719-964-8953
Practice Address - Fax:719-309-5864
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4106103G00000X, 103TC1900X, 103TC0700X, 103TC2200X, 103TH0004X, 103TM1800X, 103TR0400X, 103T00000X
HI1577103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation