Provider Demographics
NPI:1356498281
Name:DICKERSON, JENNIFER M (OTRL)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:M
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8154 SIGNAL HILL RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-1231
Mailing Address - Country:US
Mailing Address - Phone:804-730-3239
Mailing Address - Fax:
Practice Address - Street 1:40 BROAD STREET RD
Practice Address - Street 2:
Practice Address - City:MANAKIN SABOT
Practice Address - State:VA
Practice Address - Zip Code:23103-2213
Practice Address - Country:US
Practice Address - Phone:804-784-3514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119001291225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics