Provider Demographics
NPI:1891192472
Name:MITCHELL, JORDAN C (MS, ATC, CES)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:C
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MS, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 LECONTE RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-2904
Mailing Address - Country:US
Mailing Address - Phone:864-958-1655
Mailing Address - Fax:
Practice Address - Street 1:316 BOULEVARD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4002
Practice Address - Country:US
Practice Address - Phone:864-958-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC17882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program