Provider Demographics
NPI:1477929198
Name:MITCHELL, JENNIFER (BCBA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HOLCOMB WOODS PKWY
Mailing Address - Street 2:SUITE 440
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 HOLCOMB WOODS PKWY
Practice Address - Street 2:SUITE 440
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2575
Practice Address - Country:US
Practice Address - Phone:404-931-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-15-19260103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1-15-19260OtherBCBA