Provider Demographics
NPI:1912200650
Name:DICKERSON, JESSICA LEEANN (AP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEEANN
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-6404
Mailing Address - Country:US
Mailing Address - Phone:386-243-0440
Mailing Address - Fax:
Practice Address - Street 1:820 S ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-6404
Practice Address - Country:US
Practice Address - Phone:386-243-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 2856171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist