1811994023 NPI number — JESSIE D HICKS D.O.

Table of content: JESSIE D HICKS D.O. (NPI 1811994023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811994023 NPI number — JESSIE D HICKS D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKS
Provider First Name:
JESSIE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811994023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W MAGNOLIA AVE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-7657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-702-2977
Provider Business Mailing Address Fax Number:
817-702-2140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-4917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-702-1100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  K6864 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 030891903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 030891801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0028DT . This is a "BLUE LINK" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8BQ007 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 030891813 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110243367 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com