Provider Demographics
NPI:1295377125
Name:DIXON, JACOB (MHA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DIXON
Suffix:
Gender:M
Credentials:MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 AMERICAN GREETING CARD RD
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-4811
Mailing Address - Country:US
Mailing Address - Phone:606-528-7010
Mailing Address - Fax:
Practice Address - Street 1:1203 AMERICAN GREETING CARD RD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-4811
Practice Address - Country:US
Practice Address - Phone:606-528-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health