Provider Demographics
NPI:1396395349
Name:MITCHELL, JERALD
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:
Last Name:MITCHELL
Suffix:
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:PO BOX 11236
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55111-0236
Mailing Address - Country:US
Mailing Address - Phone:651-795-9596
Mailing Address - Fax:
Practice Address - Street 1:120 3RD AVE N
Practice Address - Street 2:
Practice Address - City:BIWABIK
Practice Address - State:MN
Practice Address - Zip Code:55708-3032
Practice Address - Country:US
Practice Address - Phone:218-865-4663
Practice Address - Fax:218-865-0100
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNFBL-21788-51176177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging