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General NPI Number Information
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NPI Number | 1356409734
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Entity Type | Individual
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Provider Name | JAKE EDWIN RICKETSON PSYD
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Gender | Male
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 02/09/2012
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Provider Practice Location Address
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Address Line | 405 WESTWOOD AVE
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City | HIGH POINT
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State | NC
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Zip | 27262-4325
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Country | US
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Telephone | 336-887-7350
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Fax | 336-887-7353
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Provider Business Mailing Address
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Address Line | 405 WESTWOOD AVE
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City | HIGH POINT
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State | NC
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Zip | 27262-4325
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Country | US
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Telephone | 336-887-7350
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Fax | 336-887-7353
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1167
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License Number State | NC
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