Provider Demographics
NPI:1558769349
Name:MITCHELL-WRIGHT, JAY EDWARD
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:EDWARD
Last Name:MITCHELL-WRIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:EDWARD
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:935B SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-4523
Mailing Address - Country:US
Mailing Address - Phone:530-621-6210
Mailing Address - Fax:
Practice Address - Street 1:935B SPRING ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4523
Practice Address - Country:US
Practice Address - Phone:530-621-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 215128164X00000X
CAPT 25635167G00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician