Provider Demographics
NPI:1114469202
Name:DICKERSON, JEREMY (LMT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5995 WILLIAMSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-6314
Mailing Address - Country:US
Mailing Address - Phone:302-503-2580
Mailing Address - Fax:
Practice Address - Street 1:5995 WILLIAMSVILLE RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-6314
Practice Address - Country:US
Practice Address - Phone:302-503-2580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0004366225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist