Basic Information
| Provider Information | |||||||||
| NPI: | 1700245727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JICKELL | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4550 CLYDE MORRIS BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321294080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862654769 | ||||||||
| FaxNumber: | 3867742898 | ||||||||
| Practice Location | |||||||||
| Address1: | 4550 CLYDE MORRIS BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321294080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862654769 | ||||||||
| FaxNumber: | 3867742898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2016 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY2012 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.