Provider Demographics
NPI:1578090833
Name:HICKS, JENNY FERN (DOCTORATE OF PT)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:FERN
Last Name:HICKS
Suffix:
Gender:F
Credentials:DOCTORATE OF PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8311
Mailing Address - Country:US
Mailing Address - Phone:208-263-7998
Mailing Address - Fax:
Practice Address - Street 1:1905 PINE ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-8311
Practice Address - Country:US
Practice Address - Phone:208-263-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2602251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-260OtherPHYSICAL THERAPY LICENSE NUMBER