Provider Demographics
NPI:1962410407
Name:HICKMAN, JEANNE K (GNP)
Entity type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:K
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 NORTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017
Mailing Address - Country:US
Mailing Address - Phone:269-969-6145
Mailing Address - Fax:269-969-6133
Practice Address - Street 1:632 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3249
Practice Address - Country:US
Practice Address - Phone:269-969-6145
Practice Address - Fax:269-969-6133
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJH064997363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJH064997OtherLICENSE
MIOM87660Medicare ID - Type Unspecified