Individual
JARED T MICKELSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
55 LAKE AVE N, WORCESTER, MA 01655-0002
(508) 856-1975
(774) 442-3999
Mailing address
PO BOX 415348, BOSTON, MA 02241-5348
(800) 225-8885
(508) 334-1977
Taxonomy
Speciality
Code
Description
License number
State
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
270485
MA
207RP1001X
Pulmonary Disease Physician
Primary
270485
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110115745A
—
MA
Enumeration date
04/10/2014
Last updated
11/10/2020
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