Provider Demographics
NPI:1972043966
Name:DYKSTRA, JEDIDIAH
Entity type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2596 N STOKESBERRY PL STE 180
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6282
Mailing Address - Country:US
Mailing Address - Phone:208-590-5739
Mailing Address - Fax:
Practice Address - Street 1:2596 N STOKESBERRY PL STE 180
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6282
Practice Address - Country:US
Practice Address - Phone:208-590-5739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist