Provider Demographics
NPI:1124398789
Name:DIXON, KENYON K
Entity Type:Individual
Prefix:
First Name:KENYON
Middle Name:K
Last Name:DIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3015
Mailing Address - Country:US
Mailing Address - Phone:229-931-2470
Mailing Address - Fax:229-931-2474
Practice Address - Street 1:1335 N 5TH STREET EXT
Practice Address - Street 2:PO DRAWER 1348
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3753
Practice Address - Country:US
Practice Address - Phone:229-931-2470
Practice Address - Fax:229-931-2474
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC002359101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor