Provider Demographics
NPI:1710150685
Name:WICKS, JOHN J
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:WICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 V ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-1732
Mailing Address - Country:US
Mailing Address - Phone:916-456-1876
Mailing Address - Fax:916-736-2006
Practice Address - Street 1:2128 V ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-1732
Practice Address - Country:US
Practice Address - Phone:916-456-1876
Practice Address - Fax:916-736-2006
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 7564103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical