Healthcare Provider Details

I. General information

NPI: 1295651842
Provider Name (Legal Business Name): MISTY JO DICKSON M.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2026
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11867 GRAN MEADOWS WAY
JACKSONVILLE FL
32258-1320
US

IV. Provider business mailing address

11867 GRAN MEADOWS WAY
JACKSONVILLE FL
32258-1320
US

V. Phone/Fax

Practice location:
  • Phone: 832-725-2442
  • Fax:
Mailing address:
  • Phone: 832-725-2442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-300521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: