Provider Demographics
NPI:1104808435
Name:MICKELSON, TJODE M (DC)
Entity type:Individual
Prefix:DR
First Name:TJODE
Middle Name:M
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8914 KATHLYN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63134-3552
Mailing Address - Country:US
Mailing Address - Phone:314-398-5800
Mailing Address - Fax:
Practice Address - Street 1:105 BORGA BUILDING
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1136
Practice Address - Country:US
Practice Address - Phone:636-937-3207
Practice Address - Fax:636-937-5307
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005036767111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000025922Medicare ID - Type Unspecified