Provider Demographics
NPI:1134165202
Name:DICKINSON, JENNIFER IRENE (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:IRENE
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:IRENE
Other - Last Name:JOSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2248
Mailing Address - Fax:704-945-7671
Practice Address - Street 1:9848 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5512
Practice Address - Country:US
Practice Address - Phone:704-323-2248
Practice Address - Fax:704-945-7671
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2782174400000X
NC10177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME249760099Medicaid
ME048150OtherANTHEM BC/BS ID NUMBER
MEME0246Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
NC0397730028Medicare NSC