Provider Demographics
NPI:1043884026
Name:LIM, JERICA ELAINE MICLAT (DNP, MN, BSN, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:JERICA ELAINE
Middle Name:MICLAT
Last Name:LIM
Suffix:
Gender:F
Credentials:DNP, MN, BSN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 W OSBORN RD APT 4023
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3674
Mailing Address - Country:US
Mailing Address - Phone:747-999-7516
Mailing Address - Fax:
Practice Address - Street 1:825 W OSBORN RD APT 4023
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3674
Practice Address - Country:US
Practice Address - Phone:747-999-7516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ257756363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health