=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659737039
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER DICKERSON BA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2016
-----------------------------------------------------
Last Update Date | 01/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 N BROAD ST
-----------------------------------------------------
City | WELLSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14895-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-333-5138
-----------------------------------------------------
Fax | 585-593-3907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 N BROAD ST
-----------------------------------------------------
City | WELLSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14895-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-333-5138
-----------------------------------------------------
Fax | 585-593-3907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | NYCPS-P-585
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------