Provider Demographics
NPI:1972043966
Name:DYKSTRA, JEDIDIAH
Entity Type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16899 N PAMELAS LOOP APT 101
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-6448
Mailing Address - Country:US
Mailing Address - Phone:717-926-2441
Mailing Address - Fax:
Practice Address - Street 1:1140 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2821
Practice Address - Country:US
Practice Address - Phone:208-580-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist