Provider Demographics
NPI:1326208117
Name:HICKS, JACQUELINE MICHELE (DO)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MICHELE
Last Name:HICKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:10010 FALLS OF NEUSE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8494
Practice Address - Country:US
Practice Address - Phone:919-848-6946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-15
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-00037207Q00000X
VA0116020657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC241298OtherMEDCOST
NC1326208117Medicaid
NC0012104OtherCIGNA
NC9092685OtherAETNA