1104945344 NPI number — MRS. JOLENE M. DICKERSON APN

Table of content: MRS. JOLENE M. DICKERSON APN (NPI 1104945344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104945344 NPI number — MRS. JOLENE M. DICKERSON APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERSON
Provider First Name:
JOLENE
Provider Middle Name:
M.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN
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:
1104945344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT DEPT
Provider Business Mailing Address City Name:
ROCKLAND
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19732-0191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-651-6212
Provider Business Mailing Address Fax Number:
302-651-4945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NEMOURS PEDIATRICS MILFORD
Provider Second Line Business Practice Location Address:
703 N. DUPONT HIGHWAY
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19963-1003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-422-4559
Provider Business Practice Location Address Fax Number:
302-422-4082
Provider Enumeration Date:
03/28/2007

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: 363L00000X , with the licence number:  LJ0000236 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LN0000X , with the licence number: LJ0000236 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0005X , with the licence number: LJ0000236 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0127787 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4129831 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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