Provider Demographics
NPI:1336685460
Name:MUTCHLER, JESSICA (PHD, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MUTCHLER
Suffix:
Gender:F
Credentials:PHD, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8076
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30460-1000
Mailing Address - Country:US
Mailing Address - Phone:912-478-7400
Mailing Address - Fax:
Practice Address - Street 1:62 GEORGIA AVE
Practice Address - Street 2:HOLLIS BUILDING 1119C
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4960
Practice Address - Country:US
Practice Address - Phone:912-478-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0028602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer