Provider Demographics
NPI:1437497948
Name:FICKENS, JERVIA ISHUM SIMON (ANP)
Entity Type:Individual
Prefix:MR
First Name:JERVIA
Middle Name:ISHUM SIMON
Last Name:FICKENS
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL HOSPITAL LEMOORE
Mailing Address - Street 2:937 FRANKLIN AVE
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93246-5004
Mailing Address - Country:US
Mailing Address - Phone:559-998-4208
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL LEMOORE
Practice Address - Street 2:937 FRANKLIN AVE
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93246-5004
Practice Address - Country:US
Practice Address - Phone:559-998-4208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22451363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health