Provider Demographics
NPI:1932160645
Name:DIXON, JACQUELYN (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 STONELEIGH AVE BLDG 664
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-3997
Mailing Address - Country:US
Mailing Address - Phone:914-248-5425
Mailing Address - Fax:914-248-5865
Practice Address - Street 1:670 STONELEIGH AVE BLDG 664
Practice Address - Street 2:SUITE 203
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-3997
Practice Address - Country:US
Practice Address - Phone:914-248-5425
Practice Address - Fax:914-248-5865
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP06849Medicare UPIN
NYQB0711Medicare PIN