Healthcare Provider Details

I. General information

NPI: 1518878826
Provider Name (Legal Business Name): JENNA HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 N US HIGHWAY 1 STE 107
ORMOND BEACH FL
32174-8901
US

IV. Provider business mailing address

283 RIVERBEND RD
ORMOND BEACH FL
32174-6786
US

V. Phone/Fax

Practice location:
  • Phone: 505-862-1905
  • Fax:
Mailing address:
  • Phone: 505-862-1905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH29663
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: