Provider Demographics
NPI:1811994023
Name:HICKS, JESSIE D (DO)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:D
Last Name:HICKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W MAGNOLIA AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7657
Mailing Address - Country:US
Mailing Address - Phone:817-702-2977
Mailing Address - Fax:817-702-2140
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6864207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030891903Medicaid
TX030891801Medicaid
TX0028DTOtherBLUE LINK
TX8BQ007OtherBCBS
TX030891813Medicaid
TX110243367OtherRAILROAD MEDICARE
TXG86132Medicare UPIN
TX0028DTOtherBLUE LINK