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 1:901 DOUGLAS AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2058
Mailing Address - Country:US
Mailing Address - Phone:407-865-7153
Mailing Address - Fax:407-865-7159
Practice Address - Street 1:901 DOUGLAS AVE STE 105
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2058
Practice Address - Country:US
Practice Address - Phone:407-865-7153
Practice Address - Fax:407-865-7159
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2782174400000X
NC10177225100000X
FLPENDING225100000X
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