Healthcare Provider Details

I. General information

NPI: 1306630736
Provider Name (Legal Business Name): JACOB ALLEN MITCHELL CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9888 GENESEE AVE
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

4084 CRYSTAL DAWN LN UNIT 201
SAN DIEGO CA
92122-5846
US

V. Phone/Fax

Practice location:
  • Phone: 858-834-1798
  • Fax:
Mailing address:
  • Phone: 608-697-9321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: