Provider Demographics
NPI:1952510950
Name:MIKKELSON, JILL (PT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 E MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2123
Mailing Address - Country:US
Mailing Address - Phone:435-251-1000
Mailing Address - Fax:435-688-5514
Practice Address - Street 1:1380 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2123
Practice Address - Country:US
Practice Address - Phone:435-251-1000
Practice Address - Fax:435-688-5514
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1204292401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist