MEDICARE: JESSICA LEEANN DICKERSON A.P.

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	171100000X	Acupuncturist	AP 2856	FL

General Provider Information

NPI Number	:	1912200650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LEEANN DICKERSON A.P.

Provider Business Mailing Address
First Line	:	820 S ATLANTIC AVE
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32118-6404
Country	:	US
Telephone Number	:	386-243-0440
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 S ATLANTIC AVE
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32118-6404
Country	:	US
Telephone Number	:	386-243-0440
Fax Number	:

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

Provider Enumeration Date	:	12/20/2010
Last Update Date	:	12/20/2010

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