Provider Demographics
NPI:1801350095
Name:JAMESON, MITCHELL ANTHONY
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:ANTHONY
Last Name:JAMESON
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 1:157 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4007
Mailing Address - Country:US
Mailing Address - Phone:207-745-4984
Mailing Address - Fax:
Practice Address - Street 1:157 GROVE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4007
Practice Address - Country:US
Practice Address - Phone:207-745-4984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer