Basic Information
| Provider Information | |||||||||
| NPI: | 1275773327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | CHARIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STATOM | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | CHARIS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 901 GOODYEAR AVE | ||||||||
| Address2: | |||||||||
| City: | GADSDEN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359031106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564927800 | ||||||||
| FaxNumber: | 2564945536 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 GOODYEAR AVE | ||||||||
| Address2: | |||||||||
| City: | GADSDEN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359031106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564927800 | ||||||||
| FaxNumber: | 2564945536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2009 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.