Provider Demographics
NPI:1356800742
Name:MITCHELL, JACOB ANDERSON
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDERSON
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1474 W 1460 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2262
Mailing Address - Country:US
Mailing Address - Phone:801-518-7253
Mailing Address - Fax:
Practice Address - Street 1:475 W 940 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3301
Practice Address - Country:US
Practice Address - Phone:801-357-7686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT11837364-1205207Q00000X
GA91704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty