Provider Demographics
NPI:1467091371
Name:DIXON, JERRY JR
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:DIXON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1224
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-1224
Mailing Address - Country:US
Mailing Address - Phone:662-705-2210
Mailing Address - Fax:
Practice Address - Street 1:14337 HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3689
Practice Address - Country:US
Practice Address - Phone:662-705-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)