Provider Demographics
NPI:1235486770
Name:HICKS, JENNIFER LYNN (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:HICKS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:KEIFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-1719
Mailing Address - Country:US
Mailing Address - Phone:248-396-3549
Mailing Address - Fax:
Practice Address - Street 1:1100 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1944
Practice Address - Country:US
Practice Address - Phone:479-443-4301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered