Provider Demographics
NPI:1487184487
Name:MIKKELSEN, JENNIFER (RDMS, RVT, RT(R))
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MIKKELSEN
Suffix:
Gender:F
Credentials:RDMS, RVT, RT(R)
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:STUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 E BOGARD RD STE A200
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6569
Mailing Address - Country:US
Mailing Address - Phone:907-357-2158
Mailing Address - Fax:
Practice Address - Street 1:1700 E BOGARD RD STE A200
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6569
Practice Address - Country:US
Practice Address - Phone:907-357-2158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography