MEDICARE: DR. JOHN J. WICKS

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	103G00000X	Clinical Neuropsychologist	PSY 7564	CA
2	103TC0700X	Clinical Psychologist	PSY 7564	CA

General Provider Information

NPI Number	:	1710150685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN J. WICKS

Provider Business Mailing Address
First Line	:	2128 V ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95818-1732
Country	:	US
Telephone Number	:	916-456-1876
Fax Number	:	916-736-2006

Provider Business Practice Location Address
First Line	:	2128 V ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95818-1732
Country	:	US
Telephone Number	:	916-456-1876
Fax Number	:	916-736-2006

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2008
Last Update Date	:	04/10/2008

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