Provider Demographics
NPI:1659619914
Name:MITCHELL, JEAN ALICIA (OTR/L)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ALICIA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:REDFIELD
Mailing Address - State:SD
Mailing Address - Zip Code:57469-1216
Mailing Address - Country:US
Mailing Address - Phone:605-450-9814
Mailing Address - Fax:
Practice Address - Street 1:1401 PEARL ST
Practice Address - Street 2:
Practice Address - City:FAULKTON
Practice Address - State:SD
Practice Address - Zip Code:57438-2219
Practice Address - Country:US
Practice Address - Phone:605-598-6214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0189225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist