Provider Demographics
NPI:1689143836
Name:MITCHELL, JEFFREY LANE (CP00002941)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LANE
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:CP00002941
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2007
Mailing Address - Country:US
Mailing Address - Phone:206-834-4029
Mailing Address - Fax:206-834-4091
Practice Address - Street 1:611 12TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2007
Practice Address - Country:US
Practice Address - Phone:206-834-4029
Practice Address - Fax:206-834-4091
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00002941101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty