Provider Demographics
NPI:1588215503
Name:HICKS, JACOB (PT DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8685 W. UNION HILLS DRIVE
Mailing Address - Street 2:8685 W. UNION HILLS DRIVE
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382
Mailing Address - Country:US
Mailing Address - Phone:623-486-2331
Mailing Address - Fax:623-486-3136
Practice Address - Street 1:8685 W. UNION HILLS DRIVE
Practice Address - Street 2:8685 W. UNION HILLS DRIVE
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382
Practice Address - Country:US
Practice Address - Phone:623-486-2331
Practice Address - Fax:623-486-3136
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCP000358T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist