Provider Demographics
NPI:1285030304
Name:HICKIN, JENNIE R (PT)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:R
Last Name:HICKIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5913 FAWN LN
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-2849
Mailing Address - Country:US
Mailing Address - Phone:440-740-1053
Mailing Address - Fax:
Practice Address - Street 1:5913 FAWN LN
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-2849
Practice Address - Country:US
Practice Address - Phone:440-740-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012322225100000X
NY020285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist