Provider Demographics
NPI:1043007701
Name:HICKS, JENNIFER (PRSS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 GUYAN AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1151
Mailing Address - Country:US
Mailing Address - Phone:304-360-5961
Mailing Address - Fax:
Practice Address - Street 1:1236 5TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2207
Practice Address - Country:US
Practice Address - Phone:681-204-5400
Practice Address - Fax:681-378-6108
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25-945SUD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist