Basic Information
| Provider Information | |||||||||
| NPI: | 1245735943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 284 HIGHWAY 641 N | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383201350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312132446 | ||||||||
| FaxNumber: | 7312132447 | ||||||||
| Practice Location | |||||||||
| Address1: | 284 HIGHWAY 641 N | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383201350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312132446 | ||||||||
| FaxNumber: | 7312132447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2018 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 23945 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 0000023945 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.