Provider Demographics
NPI:1427032390
Name:HICKMAN, HOLLIE JO (DO)
Entity Type:Individual
Prefix:DR
First Name:HOLLIE
Middle Name:JO
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3660
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-633-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9337208600000X
TN1957390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003106713AMedicaid
FL003305500Medicaid
FL003305500Medicaid