Provider Demographics
NPI:1093357766
Name:DICKERSON, JOHN ANDREW
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:DICKERSON
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 6531
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-0531
Mailing Address - Country:US
Mailing Address - Phone:816-279-3311
Mailing Address - Fax:
Practice Address - Street 1:3500 VILLAGE DR # GL30
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-4979
Practice Address - Country:US
Practice Address - Phone:816-545-9203
Practice Address - Fax:816-279-3311
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190389631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical