Provider Demographics
NPI:1336629948
Name:HICKSON, JORDAN DIANE (LPC, NCC)
Entity type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:DIANE
Last Name:HICKSON
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3389 SUMMIT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-2953
Mailing Address - Country:US
Mailing Address - Phone:248-505-7712
Mailing Address - Fax:
Practice Address - Street 1:3389 SUMMIT RIDGE DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48306-2953
Practice Address - Country:US
Practice Address - Phone:248-505-7712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013783101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor