Provider Demographics
NPI:1639929417
Name:HICKS, JACQUELINE (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 755
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-0755
Mailing Address - Country:US
Mailing Address - Phone:662-645-9705
Mailing Address - Fax:
Practice Address - Street 1:448 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-4908
Practice Address - Country:US
Practice Address - Phone:662-645-9705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS883789163W00000X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty