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NPI Code Detail

MEDICARE: BRENNON KEITH DICKSON MHPP

MEDICARE: BRENNON KEITH DICKSON MHPP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1171M00000XCase Manager/Care Coordinator
2171M00000XCase Manager/Care CoordinatorAR
3104100000XSocial Worker28157-MAR

General Provider Information

NPI Number : 1033426077
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRENNON KEITH DICKSON MHPP
Provider Business Mailing Address
First Line : 1815 PLEASANT GROVE RD
Second Line :
City : JONESBORO
State : AR
Zip : 72405-7870
Country : US
Telephone Number : 870-933-6886
Fax Number : 870-933-9395
Provider Business Practice Location Address
First Line : 613 N FISHER ST
Second Line :
City : JONESBORO
State : AR
Zip : 72401-2152
Country : US
Telephone Number : 870-910-3757
Fax Number : 870-910-4999
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/13/2010
Last Update Date : 03/02/2026

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