Provider Demographics
NPI:1265031090
Name:HICKMON, DAVID JORDAN (PT)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JORDAN
Last Name:HICKMON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5519A LEE AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3439
Mailing Address - Country:US
Mailing Address - Phone:501-230-0035
Mailing Address - Fax:
Practice Address - Street 1:3231 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-9201
Practice Address - Country:US
Practice Address - Phone:501-847-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist