Provider Demographics
NPI:1972801546
Name:HICKMAN, JEANETTE (MASTER)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:MASTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 MLK BLVD
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-7004
Mailing Address - Country:US
Mailing Address - Phone:561-683-4778
Mailing Address - Fax:561-683-9995
Practice Address - Street 1:2051 MLK BLVD
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-7004
Practice Address - Country:US
Practice Address - Phone:561-683-4778
Practice Address - Fax:561-683-9995
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health