Basic Information
| Provider Information | |||||||||
| NPI: | 1437275575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKKELSON | ||||||||
| FirstName: | JANNEL | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 E. HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHELAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988160908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096823300 | ||||||||
| FaxNumber: | 5096829614 | ||||||||
| Practice Location | |||||||||
| Address1: | 16120 NE 8TH ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980083937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256534308 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 06/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT00003362 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1020730 | 05 | WA | MEDICAID |