Provider Demographics
NPI:1568875870
Name:MIKOLAICHIK, JESSICA ELAINE (PA-HIS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:MIKOLAICHIK
Suffix:
Gender:F
Credentials:PA-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 STOCK ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-2266
Mailing Address - Country:US
Mailing Address - Phone:717-698-1541
Mailing Address - Fax:717-698-1430
Practice Address - Street 1:195 STOCK ST
Practice Address - Street 2:SUITE 112
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-2266
Practice Address - Country:US
Practice Address - Phone:717-698-1541
Practice Address - Fax:717-698-1430
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF03277246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF03277OtherSTATE LICENSE