Provider Demographics
NPI:1083003115
Name:MITCHELL, JENNIFER QUINN (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:QUINN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 TALCOTTVILLE RD
Mailing Address - Street 2:STE 5
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5261
Mailing Address - Country:US
Mailing Address - Phone:315-323-3825
Mailing Address - Fax:
Practice Address - Street 1:35 TALCOTTVILLE RD STE 5
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5261
Practice Address - Country:US
Practice Address - Phone:860-870-6388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09592363A00000X
CT4098363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant