=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033757877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA DIXON-TATUM LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2019
-----------------------------------------------------
Last Update Date | 04/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 N 6TH ST
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85326-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-401-6331
-----------------------------------------------------
Fax | 623-233-6331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 N 6TH ST
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85326-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-698-8210
-----------------------------------------------------
Fax | 602-455-4624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | LP040900
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number | 8900919
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 8900919
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number | 8900919
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 385HR2055X
-----------------------------------------------------
Taxonomy Name | Child Mental Illness Respite Care
-----------------------------------------------------
License Number | 8900919
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------