Provider Demographics
NPI:1487646832
Name:DICKERSON, JASON KENNETH (OD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:KENNETH
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 HIGHWAY 31 S
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-1322
Mailing Address - Country:US
Mailing Address - Phone:205-664-1575
Mailing Address - Fax:205-664-1578
Practice Address - Street 1:2617 HIGHWAY 31 S
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-1322
Practice Address - Country:US
Practice Address - Phone:205-664-1575
Practice Address - Fax:205-664-1578
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-982-TA-567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU86291OtherHEALTHSPRING
ALU86291OtherUNITED HEALTHCARE
ALU86291OtherVIVA
AL009933935Medicaid
AL51505633OtherBLUE CROSS BLUE SHIELD
ALU86291OtherUNITED HEALTHCARE
ALU86291OtherHEALTHSPRING
AL009933935Medicaid
AL051505633DICMedicare ID - Type Unspecified