MEDICARE: JESSIE D. HICKS, D.O.,P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	K6864	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110243367	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0028DT	OTHER	TX	BLUE LINK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366608051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSIE D. HICKS, D.O.,P.A.

Provider Business Mailing Address
First Line	:	4301 COLLEGE DR RM 800
Second Line	:
City	:	VERNON
State	:	TX
Zip	:	76384-3128
Country	:	US
Telephone Number	:	940-552-9323
Fax Number	:	940-552-9328

Provider Business Practice Location Address
First Line	:	4301 COLLEGE DR RM 800
Second Line	:
City	:	VERNON
State	:	TX
Zip	:	76384-3128
Country	:	US
Telephone Number	:	940-552-9323
Fax Number	:	940-552-9328

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. JESSIE DENEICE HICKS
Credential	:	D.O.
Telephone Number	:	940-552-9323

Provider Enumeration Date	:	08/01/2008
Last Update Date	:	08/01/2008

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Directions to “JESSIE D. HICKS, D.O.,P.A. ” Practice Location

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