Healthcare Provider Details

I. General information

NPI: 1669920054
Provider Name (Legal Business Name): JENNIFER HICKS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S. HARRILL AVE
WAGONER OK
74467-5867
US

IV. Provider business mailing address

1203 SE 3RD ST
WAGONER OK
74467-5823
US

V. Phone/Fax

Practice location:
  • Phone: 918-485-0242
  • Fax: 918-485-0204
Mailing address:
  • Phone: 918-815-9863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7277
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: