Provider Demographics
NPI:1659737039
Name:DICKERSON, JENNIFER (BA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1224
Mailing Address - Country:US
Mailing Address - Phone:607-333-5138
Mailing Address - Fax:585-593-3907
Practice Address - Street 1:41 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1224
Practice Address - Country:US
Practice Address - Phone:607-333-5138
Practice Address - Fax:585-593-3907
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-P-585175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist