Provider Demographics
NPI:1821675158
Name:HICKS, JESSICA TILLEY (FNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:TILLEY
Last Name:HICKS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SUZANNE
Other - Last Name:TILLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:632 SPRINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3432
Mailing Address - Country:US
Mailing Address - Phone:704-657-6367
Mailing Address - Fax:
Practice Address - Street 1:632 SPRINGDALE RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3432
Practice Address - Country:US
Practice Address - Phone:704-657-6367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC253623363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily