Provider Demographics
NPI:1427609965
Name:VANDYKE, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:VANDYKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11454 127TH AVE
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-1913
Mailing Address - Country:US
Mailing Address - Phone:727-742-7872
Mailing Address - Fax:
Practice Address - Street 1:1101 BELCHER RD S STE B
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-3356
Practice Address - Country:US
Practice Address - Phone:727-742-7872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician