Provider Demographics
NPI:1437275575
Name:MIKKELSON, JANNEL (OT)
Entity Type:Individual
Prefix:
First Name:JANNEL
Middle Name:
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 E. HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-0908
Mailing Address - Country:US
Mailing Address - Phone:509-682-3300
Mailing Address - Fax:509-682-9614
Practice Address - Street 1:16120 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-3937
Practice Address - Country:US
Practice Address - Phone:425-653-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00003362225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1020730Medicaid