Healthcare Provider Details

I. General information

NPI: 1801448543
Provider Name (Legal Business Name): VIRGINIA JACKSON DYKES DAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA E JACKSON DAT, LAT, ATC

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 HULL RD
GAINESVILLE FL
32607-4144
US

IV. Provider business mailing address

3450 HULL RD
GAINESVILLE FL
32607-4144
US

V. Phone/Fax

Practice location:
  • Phone: 229-221-9916
  • Fax:
Mailing address:
  • Phone: 229-221-9916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT004142
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL6273
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: