Healthcare Provider Details

I. General information

NPI: 1194160242
Provider Name (Legal Business Name): GLEN C JICKLING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 50TH ST RM 2415, MIND INSTITUTE, UNIVERSITY OF CALIFORNIA DAVIS
SACRAMENTO CA
95817-2312
US

IV. Provider business mailing address

2805 50TH ST RM 2415, MIND INSTITUTE, UNIVERSITY OF CALIFORNIA DAVIS
SACRAMENTO CA
95817-2312
US

V. Phone/Fax

Practice location:
  • Phone: 916-703-0449
  • Fax:
Mailing address:
  • Phone: 916-703-0449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA104529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: