Healthcare Provider Details

I. General information

NPI: 1679661037
Provider Name (Legal Business Name): JESSIE LEE DICKERSON RN, MSN, CWON, CFNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 19TH ST S
BIRMINGHAM AL
35233-1927
US

IV. Provider business mailing address

100 BLACKBERRY LN
BIRMINGHAM AL
35214-3614
US

V. Phone/Fax

Practice location:
  • Phone: 205-933-8101
  • Fax: 205-558-7022
Mailing address:
  • Phone: 205-798-7824
  • Fax: 205-558-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0900X
TaxonomyEnterostomal Therapy Registered Nurse
License Number1-036245
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: