Provider Demographics
NPI:1285021881
Name:HICKSON, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:HICKSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13960 FLORIDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:LA
Mailing Address - Zip Code:70754
Mailing Address - Country:US
Mailing Address - Phone:225-686-0158
Mailing Address - Fax:225-686-9965
Practice Address - Street 1:13960 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:LA
Practice Address - Zip Code:70754-1771
Practice Address - Country:US
Practice Address - Phone:225-686-0158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA342733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program