Provider Demographics
NPI:1508507062
Name:DIXON, JADE GB (RN)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:GB
Last Name:DIXON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 SCHLEICHER AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2330
Mailing Address - Country:US
Mailing Address - Phone:317-702-7416
Mailing Address - Fax:
Practice Address - Street 1:6919 E 10TH ST STE E1A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4892
Practice Address - Country:US
Practice Address - Phone:463-206-2120
Practice Address - Fax:317-222-6896
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28238155A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28238155COtherCOMPACT REGISTERED NURSE
IN28238155AOtherREGISTERED NURSE