Provider Demographics
NPI:1497714257
Name:DICKERSON, JILL B (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:B
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 TAPESTRY LN
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5649
Mailing Address - Country:US
Mailing Address - Phone:678-423-5560
Mailing Address - Fax:678-423-5563
Practice Address - Street 1:10 MARKET SQUARE WAY STE 100
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6078
Practice Address - Country:US
Practice Address - Phone:678-423-5560
Practice Address - Fax:678-423-5563
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061061208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA182611684AMedicaid