Provider Demographics
NPI:1023436524
Name:HICKMAN, JERRID (LPTA)
Entity type:Individual
Prefix:
First Name:JERRID
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 SILVER CROSS DR
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2388
Mailing Address - Country:US
Mailing Address - Phone:601-540-0497
Mailing Address - Fax:
Practice Address - Street 1:503 SILVER CROSS DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2388
Practice Address - Country:US
Practice Address - Phone:601-540-0497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA5335225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant