Provider Demographics
NPI:1306161682
Name:DYKSTRA, JOELLEN (PTA)
Entity type:Individual
Prefix:MRS
First Name:JOELLEN
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NEW HOLLAND
Mailing Address - State:SD
Mailing Address - Zip Code:57364-0009
Mailing Address - Country:US
Mailing Address - Phone:605-243-2232
Mailing Address - Fax:
Practice Address - Street 1:141 DAKOTA AVE. N.
Practice Address - Street 2:
Practice Address - City:NEW HOLLAND
Practice Address - State:SD
Practice Address - Zip Code:57364-0009
Practice Address - Country:US
Practice Address - Phone:605-243-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0020225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant