Provider Demographics
NPI:1790393510
Name:MIZELL, JACOB P (LMSW)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:P
Last Name:MIZELL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N LORRAINE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67501-5600
Mailing Address - Country:US
Mailing Address - Phone:620-663-7595
Mailing Address - Fax:620-513-5098
Practice Address - Street 1:1600 N LORRAINE ST STE 202
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67501-5600
Practice Address - Country:US
Practice Address - Phone:620-663-7595
Practice Address - Fax:620-513-5098
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS116841041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical