MEDICARE: MS. JEAN THERESE MITCHELL LCSW

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	104100000X	Social Worker	P005292	NC
2	1041C0700X	Clinical Social Worker	P005292	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C012988	OTHER	NC	NORTH CAROLINA SOCIAL WORK CERTIFICATION AND LICENSURE BOARD

General Provider Information

NPI Number	:	1558594101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEAN THERESE MITCHELL LCSW

Provider Business Mailing Address
First Line	:	1611 EASTCHESTER DR
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-2354
Country	:	US
Telephone Number	:	919-316-8375
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 EASTCHESTER DR
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-2354
Country	:	US
Telephone Number	:	919-316-8375
Fax Number	:

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

Provider Enumeration Date	:	08/31/2009
Last Update Date	:	05/06/2022

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