Healthcare Provider Details

I. General information

NPI: 1164004875
Provider Name (Legal Business Name): MS. JENNA R DYKSTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21550 BISCAYNE BLVD STE 202A
AVENTURA FL
33180-1258
US

IV. Provider business mailing address

15280 NW 79TH CT STE 200
MIAMI LAKES FL
33016-5873
US

V. Phone/Fax

Practice location:
  • Phone: 57-070-3683
  • Fax:
Mailing address:
  • Phone: 305-558-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116691
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: