Provider Demographics
NPI:1336296045
Name:MIKELSON, JASON ERIK (MPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ERIK
Last Name:MIKELSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W STATE ST STE F
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3696
Mailing Address - Country:US
Mailing Address - Phone:877-632-6637
Mailing Address - Fax:708-409-5179
Practice Address - Street 1:2000 W STATE ST STE F
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-3696
Practice Address - Country:US
Practice Address - Phone:877-632-6637
Practice Address - Fax:708-409-5179
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-011509OtherPT STATE LICENSE #
IL070-011509OtherPT STATE LICENSE #