Provider Demographics
NPI:1831675719
Name:MITCHELL, JENNIE L (CADC-1)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:CADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 CAMINO DEL RIO S STE 129
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3544
Mailing Address - Country:US
Mailing Address - Phone:619-282-7274
Mailing Address - Fax:
Practice Address - Street 1:1081 CAMINO DEL RIO S STE 129
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3544
Practice Address - Country:US
Practice Address - Phone:619-297-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI10830218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)