Provider Demographics
NPI:1477890382
Name:HICKS, JEREMIAH WAYNE (LCSW, CAADC, CCDPD)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:WAYNE
Last Name:HICKS
Suffix:
Gender:M
Credentials:LCSW, CAADC, CCDPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1993 CATO AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-2754
Mailing Address - Country:US
Mailing Address - Phone:814-231-8820
Mailing Address - Fax:814-231-8857
Practice Address - Street 1:1993 CATO AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-2754
Practice Address - Country:US
Practice Address - Phone:814-231-8820
Practice Address - Fax:814-231-8857
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0174371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical