Healthcare Provider Details

I. General information

NPI: 1780297135
Provider Name (Legal Business Name): MARTHA JICKA CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 CARRIAGE HILL RD STE 200
VIRGINIA BEACH VA
23452-6546
US

IV. Provider business mailing address

225 73RD ST
VIRGINIA BEACH VA
23451-1903
US

V. Phone/Fax

Practice location:
  • Phone: 757-263-2800
  • Fax:
Mailing address:
  • Phone: 201-937-7717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202008101
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: