Provider Demographics
NPI:1497898506
Name:DIXON, JENNIFER MARIE (BSRSST)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:DIXON
Suffix:
Gender:F
Credentials:BSRSST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36210 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-6385
Mailing Address - Country:US
Mailing Address - Phone:586-716-1696
Mailing Address - Fax:586-469-7960
Practice Address - Street 1:38251 S GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1929
Practice Address - Country:US
Practice Address - Phone:586-469-6210
Practice Address - Fax:586-469-7960
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803081223104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker