Provider Demographics
NPI:1477830495
Name:MITCHELL, JENNIFER MARISA (MED)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARISA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 I ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1429
Mailing Address - Country:US
Mailing Address - Phone:508-935-7515
Mailing Address - Fax:
Practice Address - Street 1:25 STANIFORD ST FL 2
Practice Address - Street 2:BOSTON EMERGENCY SERVIES TEAM
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2503
Practice Address - Country:US
Practice Address - Phone:800-981-4353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA438105101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool