Provider Demographics
NPI:1225428105
Name:DICKERSON, JESSALYN (PA)
Entity Type:Individual
Prefix:
First Name:JESSALYN
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSALYN
Other - Middle Name:
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2215 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1105
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:2508 XENIA ST
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:TX
Practice Address - Zip Code:79072-1818
Practice Address - Country:US
Practice Address - Phone:806-291-5170
Practice Address - Fax:806-291-5171
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260018982255A2300X
TXPA12907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer