Provider Demographics
NPI:1972644706
Name:MIKKELSON, JILL M (DC)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:M
Last Name:MIKKELSON
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 1:5879 WOODLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597
Mailing Address - Country:US
Mailing Address - Phone:608-849-4521
Mailing Address - Fax:608-849-8516
Practice Address - Street 1:1024 QUINN DRIVE
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597
Practice Address - Country:US
Practice Address - Phone:608-849-4521
Practice Address - Fax:608-849-8516
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3655012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor