MEDICARE: JESSICA L DIXON LCSWA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	011693	NC

General Provider Information

NPI Number	:	1255833927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA L DIXON LCSWA

Provider Business Mailing Address
First Line	:	4415 MONROE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7754
Country	:	US
Telephone Number	:	704-332-3634
Fax Number	:

Provider Business Practice Location Address
First Line	:	4415 MONROE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-7754
Country	:	US
Telephone Number	:	704-332-1801
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2018
Last Update Date	:	03/08/2018

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