Provider Demographics
NPI:1629141700
Name:HICKS, JEFFREY J (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:HICKS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 TOWER CT
Mailing Address - Street 2:STE 250
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031
Mailing Address - Country:US
Mailing Address - Phone:847-336-3020
Mailing Address - Fax:847-336-3318
Practice Address - Street 1:15 TOWER CT
Practice Address - Street 2:STE 250
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:847-336-3020
Practice Address - Fax:847-336-3318
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004968213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211632Medicare ID - Type Unspecified
U72298Medicare UPIN
WI211632Medicare ID - Type Unspecified