Provider Demographics
NPI:1063569770
Name:WICKMAN, JERRY (DC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:WICKMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-0475
Mailing Address - Country:US
Mailing Address - Phone:360-370-5500
Mailing Address - Fax:360-370-5514
Practice Address - Street 1:774 MULLIS ST STE A
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-7984
Practice Address - Country:US
Practice Address - Phone:360-370-5500
Practice Address - Fax:360-370-5514
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2414111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB17409Medicare ID - Type Unspecified
WAU37727Medicare UPIN