Provider Demographics
NPI:1487825733
Name:DYKSTRA, JULIANN KAY (BC-HIS)
Entity Type:Individual
Prefix:
First Name:JULIANN
Middle Name:KAY
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WASHINGTON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4238
Mailing Address - Country:US
Mailing Address - Phone:262-637-5668
Mailing Address - Fax:262-637-5009
Practice Address - Street 1:5200 WASHINGTON AVE STE 102
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4238
Practice Address - Country:US
Practice Address - Phone:262-637-5668
Practice Address - Fax:262-637-5009
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI402237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42812800Medicaid