Provider Demographics
NPI:1033697990
Name:DICKESS, JERRY D
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:DICKESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-5864
Mailing Address - Fax:606-408-6499
Practice Address - Street 1:613 23RD ST STE G10
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2886
Practice Address - Country:US
Practice Address - Phone:064-085-8646
Practice Address - Fax:606-408-6499
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005673363A00000X
KYPA2449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant