Healthcare Provider Details

I. General information

NPI: 1528389699
Provider Name (Legal Business Name): JENNIFER LYNN DICKERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32531 N SCOTTSDALE RD STE. 105-162
SCOTTSDALE AZ
85266-1519
US

IV. Provider business mailing address

17832 W ADDIE LN
SURPRISE AZ
85374-3880
US

V. Phone/Fax

Practice location:
  • Phone: 480-488-3946
  • Fax: 480-488-3956
Mailing address:
  • Phone: 540-597-7902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA6633
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: