Provider Demographics
NPI:1871926683
Name:MIKULA, JENNIFER NICOLE (MS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:MIKULA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:LARCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:159 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2045
Mailing Address - Country:US
Mailing Address - Phone:315-342-9575
Mailing Address - Fax:315-342-7664
Practice Address - Street 1:159 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2045
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:315-342-7664
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023850235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist