Provider Demographics
NPI:1154893626
Name:DIX, JENNIFER COLLEEN (AT, ATC, LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:COLLEEN
Last Name:DIX
Suffix:
Gender:F
Credentials:AT, ATC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2479 TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-4650
Mailing Address - Country:US
Mailing Address - Phone:216-272-3469
Mailing Address - Fax:
Practice Address - Street 1:14100 FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4516
Practice Address - Country:US
Practice Address - Phone:216-272-3469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer