Provider Demographics
NPI:1639112907
Name:MIKRUT, JEAN ANN (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:ANN
Last Name:MIKRUT
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11385
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-1385
Mailing Address - Country:US
Mailing Address - Phone:928-458-6025
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 11385
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86304-1385
Practice Address - Country:US
Practice Address - Phone:928-458-6025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ727156133V00000X
AZ278126163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106736Medicaid