Provider Demographics
NPI:1366608051
Name:JESSIE D. HICKS, D.O.,P.A.
Entity type:Organization
Organization Name:JESSIE D. HICKS, D.O.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:DENEICE
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:940-552-9323
Mailing Address - Street 1:4301 COLLEGE DR RM 800
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-3128
Mailing Address - Country:US
Mailing Address - Phone:940-552-9323
Mailing Address - Fax:940-552-9328
Practice Address - Street 1:4301 COLLEGE DR RM 800
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-3128
Practice Address - Country:US
Practice Address - Phone:940-552-9323
Practice Address - Fax:940-552-9328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6864207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0028DTOtherBLUE LINK
TX110243367OtherRAILROAD MEDICARE
TX030891801Medicaid
TX030891801Medicaid
TX00682JIMedicare PIN