MEDICARE: DR. JENNIFER C DICKENS MD

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
1	207Q00000X	Family Medicine Physician	MD 26669	SC
2	207Q00000X	Family Medicine Physician	2001-01321	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760462311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER C DICKENS MD

Provider Business Mailing Address
First Line	:	113 MILLWOOD DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29715-8356
Country	:	US
Telephone Number	:	803-802-9488
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 MILLWOOD DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29715-8356
Country	:	US
Telephone Number	:	803-802-9488
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	07/03/2008

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