Provider Demographics
NPI:1669767380
Name:MIKKELSON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-9679
Mailing Address - Country:US
Mailing Address - Phone:860-623-3327
Mailing Address - Fax:860-627-5301
Practice Address - Street 1:74 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-9679
Practice Address - Country:US
Practice Address - Phone:860-623-3327
Practice Address - Fax:860-627-5301
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0011462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist