Provider Demographics
NPI:1558495846
Name:DICKSON, JENNIFER MARIE (DPT, OMPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:DICKSON
Suffix:
Gender:F
Credentials:DPT, OMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:878 S ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2767
Mailing Address - Country:US
Mailing Address - Phone:248-601-9207
Mailing Address - Fax:248-650-8670
Practice Address - Street 1:67962 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:ROMEO
Practice Address - State:MI
Practice Address - Zip Code:48065-5163
Practice Address - Country:US
Practice Address - Phone:586-336-4022
Practice Address - Fax:586-336-4082
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010112252251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650E008430OtherBCBSM
MIN47660024Medicare PIN