Provider Demographics
NPI:1699164202
Name:FICKEN, JEREMY (NP-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:FICKEN
Suffix:
Gender:M
Credentials:NP-C
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 5204
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0603
Mailing Address - Country:US
Mailing Address - Phone:619-981-9432
Mailing Address - Fax:623-889-3478
Practice Address - Street 1:750 N ESTRELLA PKWY
Practice Address - Street 2:STE 40
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9272
Practice Address - Country:US
Practice Address - Phone:623-889-3477
Practice Address - Fax:623-889-3478
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ147824363LF0000X, 261QA0005X
CA583861261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility