Provider Demographics
NPI:1134478688
Name:MITCHELL, JENNIFER LEANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEANN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5316 TRAIL LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:545 ROWLETT RD
Practice Address - Street 2:SUITE A OR B
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043
Practice Address - Country:US
Practice Address - Phone:912-303-7021
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX676535Medicare PIN
TX456606Medicare PIN