Provider Demographics
NPI:1235218538
Name:MITCHELL, JENNIFER A
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
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 1:315 ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6486
Mailing Address - Country:US
Mailing Address - Phone:770-233-2809
Mailing Address - Fax:
Practice Address - Street 1:231 S 10TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-2803
Practice Address - Country:US
Practice Address - Phone:770-233-2809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC001607101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health