Provider Demographics
NPI:1447593249
Name:MITCHELL, JESSICA RENEE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
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 1:4913 SUGARGROVE CT
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-5017
Mailing Address - Country:US
Mailing Address - Phone:727-286-1400
Mailing Address - Fax:
Practice Address - Street 1:1995 E CORNELIUS HARNETT BLVD
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-8276
Practice Address - Country:US
Practice Address - Phone:910-893-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8580225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist