Provider Demographics
NPI:1568598027
Name:MICOU, ERICKA M (NP)
Entity Type:Individual
Prefix:MISS
First Name:ERICKA
Middle Name:M
Last Name:MICOU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-2841
Mailing Address - Country:US
Mailing Address - Phone:601-948-5572
Mailing Address - Fax:601-914-3012
Practice Address - Street 1:1134 WINTER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-2841
Practice Address - Country:US
Practice Address - Phone:601-948-5572
Practice Address - Fax:601-914-3012
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS363L00000X363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07450365Medicaid
MSQ24298Medicare UPIN