Provider Demographics
NPI:1811207277
Name:MIKOLAI, JEREMY MICHAEL (ND)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:MICHAEL
Last Name:MIKOLAI
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 SE HAWTHORNE BLVD # 132
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5246
Mailing Address - Country:US
Mailing Address - Phone:507-800-0056
Mailing Address - Fax:844-965-9136
Practice Address - Street 1:2540 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212
Practice Address - Country:US
Practice Address - Phone:507-800-0056
Practice Address - Fax:844-965-9136
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1784175F00000X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath