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NPI Code Detail

MEDICARE: JENNIFER LYNNE DYKSTRA FNP-C

MEDICARE: JENNIFER LYNNE DYKSTRA FNP-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LF0000XFamily Nurse Practitioner4704222326MI

General Provider Information

NPI Number : 1497700868
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENNIFER LYNNE DYKSTRA FNP-C
Provider Business Mailing Address
First Line : 100 MICHIGAN ST NE # MC845
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49503-2560
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 7128 FULTON ST E
Second Line :
City : ADA
State : MI
Zip : 49301-8413
Country : US
Telephone Number : 616-825-3530
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/24/2006
Last Update Date : 10/07/2022

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