Provider Demographics
NPI:1982994752
Name:HICKMAN, NELLIE JO
Entity Type:Individual
Prefix:MS
First Name:NELLIE
Middle Name:JO
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 E WOOD ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-7990
Mailing Address - Country:US
Mailing Address - Phone:731-641-4545
Mailing Address - Fax:731-641-4546
Practice Address - Street 1:2555 E WOOD ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-7990
Practice Address - Country:US
Practice Address - Phone:731-641-4545
Practice Address - Fax:731-641-4546
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN-10037-M101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)