Provider Demographics
NPI:1851071559
Name:MITCHELL, JENNIFER (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:RUNKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:954 CAMINO DE LA REINA UNIT 95
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3245
Mailing Address - Country:US
Mailing Address - Phone:619-850-5975
Mailing Address - Fax:
Practice Address - Street 1:954 CAMINO DE LA REINA UNIT 95
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3245
Practice Address - Country:US
Practice Address - Phone:619-850-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12743225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist