Provider Demographics
NPI:1104945344
Name:DICKERSON, JOLENE M (APN)
Entity type:Individual
Prefix:MRS
First Name:JOLENE
Middle Name:M
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:NEMOURS PEDIATRICS MILFORD
Practice Address - Street 2:703 N. DUPONT HIGHWAY
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1003
Practice Address - Country:US
Practice Address - Phone:302-422-4559
Practice Address - Fax:302-422-4082
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELJ0000236363L00000X, 363LN0000X, 363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0127787Medicaid
MD4129831Medicaid