MEDICARE: JILLIAN HICKS

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	235Z00000X	Speech-Language Pathologist	SLP010922	GA
2	235Z00000X	Speech-Language Pathologist	1610271	NC

General Provider Information

NPI Number	:	1740639350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLIAN HICKS

Provider Business Mailing Address
First Line	:	1568 SPRING HOLLOW WAY
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-1333
Country	:	US
Telephone Number	:	678-654-1869
Fax Number	:

Provider Business Practice Location Address
First Line	:	1568 SPRING HOLLOW WAY
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-1333
Country	:	US
Telephone Number	:	678-654-1869
Fax Number	:

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

Provider Enumeration Date	:	06/06/2016
Last Update Date	:	12/14/2021

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Directions to “ JILLIAN HICKS ” Practice Location

Language	Start Address	Practice Location

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