Healthcare Provider Details

I. General information

NPI: 1033757877
Provider Name (Legal Business Name): JESSICA DIXON-TATUM LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N 6TH ST
BUCKEYE AZ
85326-2415
US

IV. Provider business mailing address

401 N 6TH ST
BUCKEYE AZ
85326-2415
US

V. Phone/Fax

Practice location:
  • Phone: 623-401-6331
  • Fax: 623-233-6331
Mailing address:
  • Phone: 623-698-8210
  • Fax: 602-455-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP040900
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number8900919
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number8900919
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number8900919
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number8900919
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: