Provider Demographics
NPI:1679136774
Name:BICKING, REGINA JUMALON
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:JUMALON
Last Name:BICKING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 W CHARLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-2507
Mailing Address - Country:US
Mailing Address - Phone:602-526-4596
Mailing Address - Fax:602-281-2828
Practice Address - Street 1:1532 W CHARLESTON AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-2507
Practice Address - Country:US
Practice Address - Phone:602-526-4596
Practice Address - Fax:602-281-2828
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10721H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility