Healthcare Provider Details

I. General information

NPI: 1992004493
Provider Name (Legal Business Name): JOVAN HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 E 7TH ST
LONG BEACH CA
90804-4932
US

IV. Provider business mailing address

1041 REDONDO AVE
LONG BEACH CA
90804-3928
US

V. Phone/Fax

Practice location:
  • Phone: 562-987-5722
  • Fax: 562-987-4586
Mailing address:
  • Phone: 562-987-5722
  • Fax: 562-987-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: