Healthcare Provider Details

I. General information

NPI: 1144808627
Provider Name (Legal Business Name): BRANDON MICHAEL DICKINSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE STE 300
JACKSON MI
49201-1853
US

IV. Provider business mailing address

1201 E MICHIGAN AVE STE 300
JACKSON MI
49201-1853
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-7633
  • Fax:
Mailing address:
  • Phone: 517-205-7633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004444
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: