Provider Demographics
NPI:1003067695
Name:MISHOE, JEFF RANDALL (DMIN)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:RANDALL
Last Name:MISHOE
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 EAST BLVD
Mailing Address - Street 2:C-8
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4891
Mailing Address - Country:US
Mailing Address - Phone:704-344-1100
Mailing Address - Fax:704-344-1100
Practice Address - Street 1:310 EAST BLVD
Practice Address - Street 2:C-8
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4891
Practice Address - Country:US
Practice Address - Phone:704-344-1100
Practice Address - Fax:704-344-1100
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral