Provider Demographics
NPI:1073953998
Name:MICKELSON, JEANNETTE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JEANNETTE
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 GRIZZLY TRL
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MT
Mailing Address - Zip Code:59044-9476
Mailing Address - Country:US
Mailing Address - Phone:406-633-3394
Mailing Address - Fax:
Practice Address - Street 1:307 SE 4TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MT
Practice Address - Zip Code:59044-3324
Practice Address - Country:US
Practice Address - Phone:406-628-8746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist