Healthcare Provider Details

I. General information

NPI: 1619603362
Provider Name (Legal Business Name): JENNA ANNE DYKSEN M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 S SLAUSON AVE
LOS ANGELES CA
90230
US

IV. Provider business mailing address

449 GOFFLE HILL RD
HAWTHORNE NJ
07506-3017
US

V. Phone/Fax

Practice location:
  • Phone: 866-546-3733
  • Fax:
Mailing address:
  • Phone: 862-591-8019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number32822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: