Provider Demographics
NPI:1114542131
Name:HICKERSON, ALISSA J (LAC, EAMP)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:J
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:LAC, EAMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 N 115TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8206
Mailing Address - Country:US
Mailing Address - Phone:206-486-5052
Mailing Address - Fax:
Practice Address - Street 1:5607 KEYSTONE PL N STE A
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-5963
Practice Address - Country:US
Practice Address - Phone:206-486-5052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC61021576171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist