MEDICARE: JENNIFER MICKELSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2088P0231X	Pediatric Urology Physician	036.117785	IL

General Provider Information

NPI Number	:	1558518761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MICKELSON M.D.

Provider Business Mailing Address
First Line	:	1730 N CLARK ST APT 3610
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-5395
Country	:	US
Telephone Number	:	312-929-3865
Fax Number	:

Provider Business Practice Location Address
First Line	:	2300 N CHILDRENS PLZ # 24
Second Line	:	DIVISION OF UROLOGY - CHILDRENS MEMORIAL HOSPITAL
City	:	CHICAGO
State	:	IL
Zip	:	60614-3363
Country	:	US
Telephone Number	:	773-880-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2008
Last Update Date	:	08/19/2008

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