Provider Demographics
NPI:1649231408
Name:HICKS, JENNIFER O (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:O
Last Name:HICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 NISSAN PKWY
Mailing Address - Street 2:BUILDING E SUITE 100
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-7006
Mailing Address - Country:US
Mailing Address - Phone:601-855-4880
Mailing Address - Fax:601-859-2995
Practice Address - Street 1:276 NISSAN PKWY
Practice Address - Street 2:BUILDING E SUITE 100
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-7006
Practice Address - Country:US
Practice Address - Phone:601-855-4880
Practice Address - Fax:601-859-2995
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09855207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD00992OtherUPIN
MS00114331Medicaid
MS00114331Medicaid