Healthcare Provider Details

I. General information

NPI: 1992536775
Provider Name (Legal Business Name): TERREL LEONARD DIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9688 FREEFALL RD
JACKSONVILLE FL
32221-5636
US

IV. Provider business mailing address

6501 ARLINGTON EXPY STE B105
JACKSONVILLE FL
32211-0810
US

V. Phone/Fax

Practice location:
  • Phone: 904-486-6294
  • Fax:
Mailing address:
  • Phone: 904-486-6294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number1245221
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: