Healthcare Provider Details

I. General information

NPI: 1366109936
Provider Name (Legal Business Name): JAWAN ANGEL DICKERSON-ESCOBAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAISEN ASHER BEAUCHAMP MD

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3947 DEL SOL LN UNIT 103
CAPE CORAL FL
33909-5129
US

IV. Provider business mailing address

3947 DEL SOL LN UNIT 103
CAPE CORAL FL
33909-5129
US

V. Phone/Fax

Practice location:
  • Phone: 239-269-1421
  • Fax:
Mailing address:
  • Phone: 239-269-1421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: