Healthcare Provider Details

I. General information

NPI: 1356788913
Provider Name (Legal Business Name): JESSE REECE MITCHELL BCPPC, DIV, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 ACADEMY DR
HAMILTON AL
35570-3015
US

IV. Provider business mailing address

149 ACADEMY DR
HAMILTON AL
35570-3015
US

V. Phone/Fax

Practice location:
  • Phone: 205-792-1443
  • Fax:
Mailing address:
  • Phone: 205-792-1443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: