1336159094 NPI number — MISS JENNIFER BROOK DICKSON COTA/L

Table of content: MISS JENNIFER BROOK DICKSON COTA/L (NPI 1336159094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336159094 NPI number — MISS JENNIFER BROOK DICKSON COTA/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKSON
Provider First Name:
JENNIFER
Provider Middle Name:
BROOK
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
COTA/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336159094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2918 CLERMONT FARMS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BETHEL
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45106-7813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-861-3100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 S FORT THOMAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT THOMAS
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41075-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-861-3100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  OTA. 03412 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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