Provider Demographics
NPI:1255429643
Name:WICKS, KERRY W (MS, LAC, LPCC)
Entity type:Individual
Prefix:MR
First Name:KERRY
Middle Name:W
Last Name:WICKS
Suffix:
Gender:M
Credentials:MS, LAC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3952 HIGHWAY 281 SE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-9408
Mailing Address - Country:US
Mailing Address - Phone:701-252-8939
Mailing Address - Fax:
Practice Address - Street 1:3952 HIGHWAY 281 SE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-9408
Practice Address - Country:US
Practice Address - Phone:701-252-8939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND9202OtherBCBS IDENTIFIER
NDWIC17788OtherBCBS IDENTIFIER