Healthcare Provider Details

I. General information

NPI: 1699164202
Provider Name (Legal Business Name): JEREMY FICKEN NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N ESTRELLA PKWY STE 40
GOODYEAR AZ
85338-9272
US

IV. Provider business mailing address

PO BOX 5204
GOODYEAR AZ
85338-0603
US

V. Phone/Fax

Practice location:
  • Phone: 623-889-3477
  • Fax: 623-889-3478
Mailing address:
  • Phone: 619-981-9432
  • Fax: 623-889-3478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number147824
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number583861
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number147824
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: