Provider Demographics
NPI:1649437757
Name:DYKSTRA, JEAN (DO)
Entity type:Individual
Prefix:MS
First Name:JEAN
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2693 W MALAD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4110
Mailing Address - Country:US
Mailing Address - Phone:913-642-4900
Mailing Address - Fax:913-381-3454
Practice Address - Street 1:9501 N OAK TRFY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2256
Practice Address - Country:US
Practice Address - Phone:816-455-0661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-18
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090382852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology