Provider Demographics
NPI:1831128669
Name:MIKULICH, JENNIFER A (RD CD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MIKULICH
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 WESTHILL DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2720 PLAZA DR
Practice Address - Street 2:SUITE 1400
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4158
Practice Address - Country:US
Practice Address - Phone:715-847-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI370133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered