=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679940597
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB DICKERSON LPC, RPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2015
-----------------------------------------------------
Last Update Date | 06/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 RIDGEWAY ST STE 1
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71901-7155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-627-2503
-----------------------------------------------------
Fax | 501-222-1282
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7232 HIGHWAY 7
-----------------------------------------------------
City | BISMARCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71929-7105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-627-2503
-----------------------------------------------------
Fax | 501-222-1282
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A1704202
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------