Provider Demographics
NPI:1376016360
Name:DICKEN, JAIMI DELANE (LNV)
Entity Type:Individual
Prefix:
First Name:JAIMI
Middle Name:DELANE
Last Name:DICKEN
Suffix:
Gender:F
Credentials:LNV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1965 SILVER HAWK DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-4734
Mailing Address - Country:US
Mailing Address - Phone:469-237-1769
Mailing Address - Fax:
Practice Address - Street 1:2100 GARRISON DR
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7283
Practice Address - Country:US
Practice Address - Phone:469-237-1769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205138164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104374100Medicaid