Provider Demographics
NPI:1942990957
Name:HICKS, JENNA (PA-C)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:DUFFY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3507 LEE BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-1303
Mailing Address - Country:US
Mailing Address - Phone:239-368-8071
Mailing Address - Fax:239-368-8074
Practice Address - Street 1:3507 LEE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-1303
Practice Address - Country:US
Practice Address - Phone:239-368-8071
Practice Address - Fax:239-368-8074
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
FLPA9117214363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118763100Medicaid