Provider Demographics
NPI:1396866364
Name:DICKINSON, JACOB LEE (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:LEE
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BURNETT DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2908
Mailing Address - Country:US
Mailing Address - Phone:870-425-9120
Mailing Address - Fax:
Practice Address - Street 1:901 BURNETT DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2908
Practice Address - Country:US
Practice Address - Phone:870-425-9120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-5452208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR168854001Medicaid
AR5H193Medicare PIN