Healthcare Provider Details

I. General information

NPI: 1871206177
Provider Name (Legal Business Name): CRYSTAL JENNIFER HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5110 S RURAL RD STE 104
TEMPE AZ
85282-7289
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 1600
DOWNERS GROVE IL
60515-1211
US

V. Phone/Fax

Practice location:
  • Phone: 480-222-0655
  • Fax: 480-222-1457
Mailing address:
  • Phone: 866-370-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberLPT-32758
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: