Provider Demographics
NPI:1083912307
Name:MITCHELL, JENNIFER (PHD, BCBA-D)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S 400 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2908
Mailing Address - Country:US
Mailing Address - Phone:801-582-5534
Mailing Address - Fax:801-582-5540
Practice Address - Street 1:5242 S 4820 W
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-6422
Practice Address - Country:US
Practice Address - Phone:801-966-4251
Practice Address - Fax:801-966-4289
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT8431995-2501103TC0700X
UT8431995-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst