Provider Demographics
NPI:1164004875
Name:DYKSTRA, JENNA R
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:R
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15280 NW 79TH CT STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5873
Mailing Address - Country:US
Mailing Address - Phone:305-558-3724
Mailing Address - Fax:
Practice Address - Street 1:21550 BISCAYNE BLVD STE 202A
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1258
Practice Address - Country:US
Practice Address - Phone:057-070-3683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116691363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program