Kenneth Willie Dickerson Sr.

Primary specialty

DriverTaxonomy code 172A00000X

License

24512126 Issued in TX

Practice address

15530 Ella Blvd Apt 719
Houston, TX 77090

Phone

(832) 892-1079

NPI assigned

Apr 19, 2017

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1492560000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1492560000000",
    "number": "1043744790",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15530 ELLA BLVD APT 719",
            "city": "HOUSTON",
            "state": "TX",
            "postal_code": "770905310",
            "telephone_number": "832-892-1079"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15530 ELLA BLVD APT 719",
            "city": "HOUSTON",
            "state": "TX",
            "postal_code": "77090",
            "telephone_number": "832-892-1079"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DICKERSON",
        "first_name": "KENNETH",
        "middle_name": "WILLIE",
        "name_suffix": "Sr.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2017-04-19",
        "last_updated": "2017-04-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "172A00000X",
            "taxonomy_group": "",
            "desc": "Driver",
            "state": "TX",
            "license": "24512126",
            "primary": true
        },
        {
            "code": "405300000X",
            "taxonomy_group": "",
            "desc": "Prevention Professional",
            "state": "TX",
            "license": "24512126",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Diana Lynn Dickens, MD
• Jordan Taylor Dickens, APRN, PMHNP-BC
• Cristin A Dickerson, M.D.
• Heather Anne Dickerson, M.D.
• Karen Waldrop Dickerson, PHD. CCC-SLP
• Lindsay Kathleen Dickerson, MD
• Robin Michelle Dickerson, R.T.(R)(T)
• Thomas Bernard Dickerson, LCDCI
• Adam Dickey
• Burton F. Dickey, M.D.

• Driver in Houston, TX
• Providers in Houston, TX by specialty
• Driver in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 19, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.