Healthcare Provider Details

I. General information

NPI: 1649437757
Provider Name (Legal Business Name): JEAN DYKSTRA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2008
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 N OAK TRFY
KANSAS CITY MO
64155-2256
US

IV. Provider business mailing address

2693 W MALAD ST
BOISE ID
83705-4110
US

V. Phone/Fax

Practice location:
  • Phone: 816-455-0661
  • Fax:
Mailing address:
  • Phone: 913-642-4900
  • Fax: 913-381-3454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2009038285
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: