Healthcare Provider Details

I. General information

NPI: 1457388142
Provider Name (Legal Business Name): JEAN MIKULA D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4056 PLAINFIELD AVE NE STE. E
GRAND RAPIDS MI
49525-1630
US

IV. Provider business mailing address

4029 PLAINFIELD AVE NE # B
GRAND RAPIDS MI
49525-1628
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-0255
  • Fax: 616-365-0975
Mailing address:
  • Phone: 616-365-0255
  • Fax: 616-365-0975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301007184
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: