Healthcare Provider Details

I. General information

NPI: 1669511341
Provider Name (Legal Business Name): JEREMIAH E DICKERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S PROSPECT ST 3RD FLOOR
BURLINGTON VT
05401-3456
US

IV. Provider business mailing address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-0000
  • Fax:
Mailing address:
  • Phone: 802-847-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number042-0011801
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: