Provider Demographics
NPI:1063697381
Name:HICKMAN, JENNIFER (MAC, LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:MAC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BROAD ST
Mailing Address - Street 2:STE 202B
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1052
Mailing Address - Country:US
Mailing Address - Phone:410-641-9888
Mailing Address - Fax:410-641-9844
Practice Address - Street 1:29 BROAD ST
Practice Address - Street 2:STE 202B
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1052
Practice Address - Country:US
Practice Address - Phone:410-641-9888
Practice Address - Fax:410-641-9844
Is Sole Proprietor?:No
Enumeration Date:2008-01-05
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01230171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD62156804OtherBLUECROSS BLUESHIELD
MDC366001OtherCAREFIEST BLUECHOICE