Healthcare Provider Details

I. General information

NPI: 1225428105
Provider Name (Legal Business Name): JESSALYN DICKERSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSALYN STONE

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 XENIA ST
PLAINVIEW TX
79072-1818
US

IV. Provider business mailing address

2215 NASHVILLE AVE
LUBBOCK TX
79410-1105
US

V. Phone/Fax

Practice location:
  • Phone: 806-291-5170
  • Fax: 806-291-5171
Mailing address:
  • Phone: 806-725-5844
  • Fax: 806-723-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126001898
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12907
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: