Provider Demographics
NPI:1821622663
Name:JANSEN, MIKAYLA (DPT)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:JANSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-454-4229
Mailing Address - Fax:920-993-5001
Practice Address - Street 1:130 2ND ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2883
Practice Address - Country:US
Practice Address - Phone:920-729-3100
Practice Address - Fax:920-729-3167
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
WI14960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist