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General NPI Number Information
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NPI Number | 1164004875
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Entity Type | Individual
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Provider Name | MS. JENNA R DYKSTRA
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Gender | Female
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Dates
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Enumeration Date | 04/22/2021
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Last Update Date | 02/06/2023
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Provider Practice Location Address
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Address Line | 21550 BISCAYNE BLVD STE 202A
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City | AVENTURA
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State | FL
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Zip | 33180-1258
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Country | US
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Telephone | 57-070-3683
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Fax |
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Provider Business Mailing Address
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Address Line | 15280 NW 79TH CT STE 200
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City | MIAMI LAKES
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State | FL
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Zip | 33016-5873
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Country | US
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Telephone | 305-558-3724
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9116691
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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