Provider Demographics
NPI:1164656757
Name:DIXON, JENNIFER RENEE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
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 1:769 W BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3970
Mailing Address - Country:US
Mailing Address - Phone:951-358-6895
Mailing Address - Fax:
Practice Address - Street 1:769 W BLAINE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3970
Practice Address - Country:US
Practice Address - Phone:951-358-6895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63969106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist