Provider Demographics
NPI:1356409734
Name:RICKETSON, JAKE EDWIN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:EDWIN
Last Name:RICKETSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4325
Mailing Address - Country:US
Mailing Address - Phone:336-887-7350
Mailing Address - Fax:336-887-7353
Practice Address - Street 1:405 WESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4325
Practice Address - Country:US
Practice Address - Phone:336-887-7350
Practice Address - Fax:336-887-7353
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1167103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC04492OtherBCBS PRIVATE INSURANCE
NC6000026Medicaid
NC21519OtherMEDCAST PRIVATE INSURANCE
NC04492OtherBCBS PRIVATE INSURANCE
R77998Medicare UPIN