Provider Demographics
NPI:1366867657
Name:MITCHELL, JEREMIAH JR
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 KENTSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3927
Mailing Address - Country:US
Mailing Address - Phone:213-640-7174
Mailing Address - Fax:
Practice Address - Street 1:8001 KENTSHIRE DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3927
Practice Address - Country:US
Practice Address - Phone:213-640-7174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2600020087101YM0800X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1129Medicaid
NV1017Medicaid
NV1023Medicaid
NV0101Medicaid