Healthcare Provider Details

I. General information

NPI: 1346911500
Provider Name (Legal Business Name): JARED DYKES APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5270 BABCOCK ST NE STE 1
PALM BAY FL
32905-4616
US

IV. Provider business mailing address

PO BOX 1137
MELBOURNE FL
32902-1137
US

V. Phone/Fax

Practice location:
  • Phone: 321-722-5959
  • Fax:
Mailing address:
  • Phone: 321-952-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9304261
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11015629
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: