Provider Demographics
NPI:1508672973
Name:DIXON, JACOB TYLER (BSW TCM)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:TYLER
Last Name:DIXON
Suffix:
Gender:M
Credentials:BSW TCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 CARCASSONNE RD
Mailing Address - Street 2:
Mailing Address - City:BLACKEY
Mailing Address - State:KY
Mailing Address - Zip Code:41804-9066
Mailing Address - Country:US
Mailing Address - Phone:606-335-0185
Mailing Address - Fax:
Practice Address - Street 1:1726 CARCASSONNE RD
Practice Address - Street 2:
Practice Address - City:BLACKEY
Practice Address - State:KY
Practice Address - Zip Code:41804-9066
Practice Address - Country:US
Practice Address - Phone:606-335-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst