Provider Demographics
NPI:1255949939
Name:HICKS, JAZZ LESOLEIL (NP, CNM)
Entity type:Individual
Prefix:
First Name:JAZZ
Middle Name:LESOLEIL
Last Name:HICKS
Suffix:
Gender:F
Credentials:NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 OBERY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2237
Mailing Address - Country:US
Mailing Address - Phone:085-830-6116
Mailing Address - Fax:
Practice Address - Street 1:46 OBERY ST STE 200
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2237
Practice Address - Country:US
Practice Address - Phone:085-830-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104674984363LW0102X
MARN2309018367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health