Healthcare Provider Details

I. General information

NPI: 1174710172
Provider Name (Legal Business Name): JANNAVIE DAWN HICKMAN M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JANNAVIE DAWN CROGAN M.A.

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6765 GREEN VALLEY RD
PLACERVILLE CA
95667-8984
US

IV. Provider business mailing address

6765 GREEN VALLEY RD
PLACERVILLE CA
95667-8984
US

V. Phone/Fax

Practice location:
  • Phone: 530-622-5551
  • Fax: 530-622-5800
Mailing address:
  • Phone: 530-622-5551
  • Fax: 530-622-5800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: