Provider Demographics
NPI:1740889195
Name:DICKSON, JAILYN
Entity type:Individual
Prefix:
First Name:JAILYN
Middle Name:
Last Name:DICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 E DELAVAN AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14208-1313
Mailing Address - Country:US
Mailing Address - Phone:716-256-8659
Mailing Address - Fax:
Practice Address - Street 1:298 E DELAVAN AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14208-1313
Practice Address - Country:US
Practice Address - Phone:716-256-8659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339182164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty