Provider Demographics
NPI:1275157554
Name:MICKELSEN, JESSICA (BS, CNIM, LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MICKELSEN
Suffix:
Gender:F
Credentials:BS, CNIM, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9720 GLADIOLUS PRESERVE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-9720
Mailing Address - Country:US
Mailing Address - Phone:239-671-0695
Mailing Address - Fax:
Practice Address - Street 1:13440 PARKER COMMONS BLVD STE 103
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1816
Practice Address - Country:US
Practice Address - Phone:239-671-0695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA92171225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist