Basic Information
| Provider Information | |||||||||
| NPI: | 1417999590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPERCO | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | HICKS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 927 FRANKLIN ST SE | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564283000 | ||||||||
| FaxNumber: | 2564283003 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 FRANKLIN ST SE | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564283000 | ||||||||
| FaxNumber: | 2564283003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | PTH3360 | AL | Y | Other Service Providers | Specialist |
No ID Information.