Provider Demographics
NPI:1003278326
Name:HICKS, JORDYN
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:693 E 1250 S
Mailing Address - Street 2:
Mailing Address - City:HAUBSTADT
Mailing Address - State:IN
Mailing Address - Zip Code:47639-8709
Mailing Address - Country:US
Mailing Address - Phone:812-632-1345
Mailing Address - Fax:
Practice Address - Street 1:251 HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:NEW HARMONY
Practice Address - State:IN
Practice Address - Zip Code:47631-9075
Practice Address - Country:US
Practice Address - Phone:812-682-4105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005931A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist