=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609453497
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB WAYNE HICKSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2021
-----------------------------------------------------
Last Update Date | 03/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2112 NEW HAMPSHIRE AVE NW APT 1007
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20009-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-422-9537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2112 NEW HAMPSHIRE AVE NW APT 1007
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20009-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | RN1036244
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------