Provider Demographics
NPI:1003628447
Name:MIHKELSON, JACOB PHILLIP (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:PHILLIP
Last Name:MIHKELSON
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:PHILLIP
Other - Last Name:MIHKELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:200 SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1114
Mailing Address - Country:US
Mailing Address - Phone:781-687-2000
Mailing Address - Fax:
Practice Address - Street 1:200 SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1114
Practice Address - Country:US
Practice Address - Phone:781-687-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN10030124363LP0808X, 163W00000X
CA95381885163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse