Provider Demographics
NPI:1952596595
Name:HICKERSON, JENNIFER JEANINE (MA/CCC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JEANINE
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:MA/CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 N FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3833
Mailing Address - Country:US
Mailing Address - Phone:316-682-5044
Mailing Address - Fax:
Practice Address - Street 1:233 N FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3833
Practice Address - Country:US
Practice Address - Phone:316-682-5044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS884235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist