Provider Demographics
NPI:1497716773
Name:WICKESBERG, JENNIFER (AUD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WICKESBERG
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 HOUSTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-6237
Mailing Address - Country:US
Mailing Address - Phone:713-523-3633
Mailing Address - Fax:713-523-8399
Practice Address - Street 1:3636 W DALLAS ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77019-1704
Practice Address - Country:US
Practice Address - Phone:713-523-4722
Practice Address - Fax:713-523-8399
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51231237600000X, 237700000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167277602Medicaid
TX167277601Medicaid
TX167277604Medicaid
TX167277603Medicaid
TX167277605Medicaid
TX167277602Medicaid
TX167277605Medicaid