MEDICARE: JENNIFER C HICKS NCTMB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1013009737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER C HICKS NCTMB

Provider Business Mailing Address
First Line	:	914 13TH AVE S
Second Line	:
City	:	GREAT FALLS
State	:	MT
Zip	:	59405-4406
Country	:	US
Telephone Number	:	406-761-3767
Fax Number	:	406-761-3038

Provider Business Practice Location Address
First Line	:	914 13TH AVE S
Second Line	:
City	:	GREAT FALLS
State	:	MT
Zip	:	59405-4406
Country	:	US
Telephone Number	:	406-761-3767
Fax Number	:	406-761-3038

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	07/08/2007

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