Provider Demographics
NPI:1275275307
Name:THACKER, JERRICK (MSN APRN FNP-C)
Entity Type:Individual
Prefix:MR
First Name:JERRICK
Middle Name:
Last Name:THACKER
Suffix:
Gender:M
Credentials:MSN APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13024 HESPERIA RD. SUIT 103
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395
Mailing Address - Country:US
Mailing Address - Phone:760-241-3547
Mailing Address - Fax:
Practice Address - Street 1:13024 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8302
Practice Address - Country:US
Practice Address - Phone:760-241-3547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-09
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020352363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner