Provider Demographics
NPI:1750801361
Name:HICKS, JEREMY ALEXANDER (CMT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:ALEXANDER
Last Name:HICKS
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 LAS FLORES DR APT A
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-1972
Mailing Address - Country:US
Mailing Address - Phone:619-519-3632
Mailing Address - Fax:
Practice Address - Street 1:183 LAS FLORES DR APT A
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-1972
Practice Address - Country:US
Practice Address - Phone:619-519-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner