Provider Demographics
NPI:1457585002
Name:MITCHELL, JILL MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:MARIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W GREENLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-2898
Mailing Address - Country:US
Mailing Address - Phone:517-485-8217
Mailing Address - Fax:
Practice Address - Street 1:405 W GREENLAWN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2898
Practice Address - Country:US
Practice Address - Phone:517-485-8217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018129207R00000X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6970024OtherMEDICARE PTAN