Provider Demographics
NPI:1922435205
Name:HICKMAN TEMPLE, JERRI KAY (MED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JERRI
Middle Name:KAY
Last Name:HICKMAN TEMPLE
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BROADWELL OAKS CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-1589
Mailing Address - Country:US
Mailing Address - Phone:404-964-4629
Mailing Address - Fax:770-754-5998
Practice Address - Street 1:135 BROADWELL OAKS CT
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-1589
Practice Address - Country:US
Practice Address - Phone:404-964-4629
Practice Address - Fax:770-754-5998
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003974235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000809839AMedicaid