Provider Demographics
NPI:1518941277
Name:MITCHELL, JEANICE AMY (MPT)
Entity Type:Individual
Prefix:
First Name:JEANICE
Middle Name:AMY
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JEANICE
Other - Middle Name:AMY
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10340
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76547-0340
Mailing Address - Country:US
Mailing Address - Phone:254-699-3933
Mailing Address - Fax:
Practice Address - Street 1:3816 S CLEAR CREEK RD
Practice Address - Street 2:SUITE B
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4400
Practice Address - Country:US
Practice Address - Phone:254-699-3933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142451702Medicaid
TX8T0447OtherBCBS
TX142451702Medicaid