Provider Demographics
NPI:1245735943
Name:HICKS, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:284 HIGHWAY 641 N
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38320-1350
Mailing Address - Country:US
Mailing Address - Phone:731-213-2446
Mailing Address - Fax:731-213-2447
Practice Address - Street 1:284 HIGHWAY 641 N
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:TN
Practice Address - Zip Code:38320-1350
Practice Address - Country:US
Practice Address - Phone:731-213-2446
Practice Address - Fax:731-213-2447
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23945363LF0000X
TN0000023945363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily