Provider Demographics
NPI:1972719151
Name:RICKERT, JEFF CHARLES (PA)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:CHARLES
Last Name:RICKERT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-1029
Mailing Address - Country:US
Mailing Address - Phone:972-771-9081
Mailing Address - Fax:972-772-7102
Practice Address - Street 1:1005 W RALPH M HALL PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6658
Practice Address - Country:US
Practice Address - Phone:972-771-9081
Practice Address - Fax:972-772-7102
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04912OtherPHYSICIAN ASSISTANT