Healthcare Provider Details

I. General information

NPI: 1124586995
Provider Name (Legal Business Name): JACQUALINE DRAKE DICKSON FNP - C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 HALLE PARK DR
COLLIERVILLE TN
38017-7085
US

IV. Provider business mailing address

8418 REGAL BEND DR
OLIVE BRANCH MS
38654-4415
US

V. Phone/Fax

Practice location:
  • Phone: 901-910-3246
  • Fax:
Mailing address:
  • Phone: 662-512-2237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000024154
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902387
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: