Provider Demographics
NPI:1588898753
Name:JEFF HICKMAN LLC
Entity type:Organization
Organization Name:JEFF HICKMAN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, PA-C
Authorized Official - Phone:580-510-3005
Mailing Address - Street 1:13811 SW BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:FAXON
Mailing Address - State:OK
Mailing Address - Zip Code:73540-4418
Mailing Address - Country:US
Mailing Address - Phone:580-510-3005
Mailing Address - Fax:
Practice Address - Street 1:202 W MISSOURI ST
Practice Address - Street 2:
Practice Address - City:WALTERS
Practice Address - State:OK
Practice Address - Zip Code:73572-1246
Practice Address - Country:US
Practice Address - Phone:580-875-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3926111N00000X
OK1298261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty