Provider Demographics
NPI:1952633166
Name:DIJKSTRA, ETZER-JAN (PT)
Entity Type:Individual
Prefix:
First Name:ETZER-JAN
Middle Name:
Last Name:DIJKSTRA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7414 AUTUMN WOOD DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-8805
Mailing Address - Country:US
Mailing Address - Phone:717-903-0488
Mailing Address - Fax:
Practice Address - Street 1:7414 AUTUMN WOOD DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-8805
Practice Address - Country:US
Practice Address - Phone:717-903-0488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT019715225100000X
VA2305204052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist