Provider Demographics
NPI:1477946697
Name:HICKS, JAMEL (LMT)
Entity Type:Individual
Prefix:
First Name:JAMEL
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 WHITE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8222
Mailing Address - Country:US
Mailing Address - Phone:304-367-1206
Mailing Address - Fax:
Practice Address - Street 1:2831 WHITE HALL BLVD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8222
Practice Address - Country:US
Practice Address - Phone:304-367-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2009-2537225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist