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General NPI Number Information
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NPI Number | 1356606487
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Entity Type | Individual
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Provider Name | JACOB JOHN DICKINSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/04/2012
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Last Update Date | 03/24/2021
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Provider Practice Location Address
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Address Line | 8111 S EMERSON AVE
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City | INDIANAPOLIS
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State | IN
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Zip | 46237-8601
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Country | US
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Telephone | 317-528-8148
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7112
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City | INDIANAPOLIS
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State | IN
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Zip | 46207-7112
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Country | US
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Telephone | 317-528-8148
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 4301100480
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 01075221A
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License Number State | IN
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