Provider Demographics
NPI:1821340399
Name:MICKULIK, JONATHAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:MICKULIK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 US HIGHWAY 46
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-1954
Mailing Address - Country:US
Mailing Address - Phone:570-606-5399
Mailing Address - Fax:
Practice Address - Street 1:461 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-1954
Practice Address - Country:US
Practice Address - Phone:570-606-5399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01463100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist