Provider Demographics
NPI:1205433109
Name:FICK, JACQUELINE POWELL (DMD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:POWELL
Last Name:FICK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8108 S 152ND AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68138-3314
Mailing Address - Country:US
Mailing Address - Phone:859-640-0559
Mailing Address - Fax:
Practice Address - Street 1:8410 S 73RD PLZ
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-1513
Practice Address - Country:US
Practice Address - Phone:402-592-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-04
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0006817-C1122300000X
NE77711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist