MEDICARE: JENELLE MARIE DIXON

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1861048811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENELLE MARIE DIXON

Provider Business Mailing Address
First Line	:	1228 DUNHAM ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-2630
Country	:	US
Telephone Number	:	616-802-8008
Fax Number	:

Provider Business Practice Location Address
First Line	:	1228 DUNHAM ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-2630
Country	:	US
Telephone Number	:	616-802-8008
Fax Number	:

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

Provider Enumeration Date	:	08/15/2019
Last Update Date	:	11/27/2023

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