Provider Demographics
NPI:1316207418
Name:HICKERSON, JAMES WILLIS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WILLIS
Last Name:HICKERSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WILL
Other - Middle Name:
Other - Last Name:HICKERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:651 DUNLOP LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5015
Mailing Address - Country:US
Mailing Address - Phone:931-502-1370
Mailing Address - Fax:
Practice Address - Street 1:651 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5015
Practice Address - Country:US
Practice Address - Phone:931-502-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48514207P00000X
TN54424207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine