Provider Demographics
NPI:1447860689
Name:HICKS, JACQUELYN SUZANNE
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:SUZANNE
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-1162
Mailing Address - Country:US
Mailing Address - Phone:517-604-8083
Mailing Address - Fax:
Practice Address - Street 1:351 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-1162
Practice Address - Country:US
Practice Address - Phone:517-604-8083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401223031101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor