Provider Demographics
NPI:1528593233
Name:DICKERSON, JENNIFER MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-1209
Mailing Address - Country:US
Mailing Address - Phone:843-652-8220
Mailing Address - Fax:843-520-8365
Practice Address - Street 1:4040 HIGHWAY 17
Practice Address - Street 2:SUITE 206
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5098
Practice Address - Country:US
Practice Address - Phone:843-652-8260
Practice Address - Fax:843-652-8269
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2731OtherSC LICENSE