Basic Information
| Provider Information | |||||||||
| NPI: | 1447860689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | SUZANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 COVENTRY LN | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488541162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174998070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 N WASHINGTON SQ STE 300 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489331658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174998070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2020 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401223031 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.