Provider Demographics
NPI:1780947234
Name:MITCHELL, JILL (LPTA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12303 HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2780
Mailing Address - Country:US
Mailing Address - Phone:228-832-6221
Mailing Address - Fax:228-832-4033
Practice Address - Street 1:12303 HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2780
Practice Address - Country:US
Practice Address - Phone:228-832-6221
Practice Address - Fax:228-832-4033
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4339225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant