Provider Demographics
NPI:1073212544
Name:HICKS, JAZMYNE S (LMT)
Entity Type:Individual
Prefix:
First Name:JAZMYNE
Middle Name:S
Last Name:HICKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 VIRGINIA BEACH BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-3412
Mailing Address - Country:US
Mailing Address - Phone:757-529-0808
Mailing Address - Fax:
Practice Address - Street 1:3707 VIRGINIA BEACH BLVD STE 210
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-3412
Practice Address - Country:US
Practice Address - Phone:757-529-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019018762225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist