MEDICARE: JEREMIAH MITCHELL JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2600020087	NV
2	172V00000X	Community Health Worker	2600020087	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366867657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMIAH MITCHELL JR.

Provider Business Mailing Address
First Line	:	8001 KENTSHIRE DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3927
Country	:	US
Telephone Number	:	213-640-7174
Fax Number	:

Provider Business Practice Location Address
First Line	:	8001 KENTSHIRE DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3927
Country	:	US
Telephone Number	:	213-640-7174
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2014
Last Update Date	:	02/24/2014

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