Provider Demographics
NPI:1033757877
Name:DIXON-TATUM, JESSICA (LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DIXON-TATUM
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-2415
Mailing Address - Country:US
Mailing Address - Phone:623-698-8210
Mailing Address - Fax:602-455-4624
Practice Address - Street 1:401 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-2415
Practice Address - Country:US
Practice Address - Phone:623-401-6331
Practice Address - Fax:623-233-6331
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP040900164W00000X
AZ8900919251J00000X, 251E00000X, 253J00000X, 385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No251E00000XAgenciesHome Health
No253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child