Provider Demographics
NPI:1700245727
Name:JICKELL, DANA (AUD)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:
Last Name:JICKELL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 CLYDE MORRIS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4080
Mailing Address - Country:US
Mailing Address - Phone:386-265-4769
Mailing Address - Fax:386-774-2898
Practice Address - Street 1:4550 CLYDE MORRIS BLVD STE B
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4080
Practice Address - Country:US
Practice Address - Phone:386-265-4769
Practice Address - Fax:386-774-2898
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-18
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY2012231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist