Provider Demographics
NPI:1497989123
Name:MICKELSON, JAYME LEIGH (DO)
Entity Type:Individual
Prefix:DR
First Name:JAYME
Middle Name:LEIGH
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PINE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-6948
Mailing Address - Country:US
Mailing Address - Phone:860-584-8291
Mailing Address - Fax:860-581-8354
Practice Address - Street 1:22 PINE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6948
Practice Address - Country:US
Practice Address - Phone:860-584-8291
Practice Address - Fax:860-581-8354
Is Sole Proprietor?:No
Enumeration Date:2009-05-09
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55713207R00000X
CT053732207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110015725Medicare PIN