Healthcare Provider Details

I. General information

NPI: 1770199630
Provider Name (Legal Business Name): MISS JORDYN RAYE DYKEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. JORDYN RAYE SCHNEIDER

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 VIA VERA CRUZ STE 102
SAN MARCOS CA
92078-2636
US

IV. Provider business mailing address

21600 OXNARD ST STE 1800
WOODLAND HILLS CA
91367-7807
US

V. Phone/Fax

Practice location:
  • Phone: 760-621-9133
  • Fax:
Mailing address:
  • Phone: 818-345-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberS53643699777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: