Provider Demographics
NPI:1295113694
Name:DICKSON, JEREMY W (MA, LPC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:W
Last Name:DICKSON
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5011
Practice Address - Street 1:323 E GRAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-761-5600
Practice Address - Fax:417-761-5601
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015014046101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490021929Medicaid