Healthcare Provider Details

I. General information

NPI: 1104280825
Provider Name (Legal Business Name): JERRELL LEE MITCHELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 WILSHIRE BLVD STE 1410
LOS ANGELES CA
90048-5815
US

IV. Provider business mailing address

6200 WILSHIRE BLVD STE 1410
LOS ANGELES CA
90048-5815
US

V. Phone/Fax

Practice location:
  • Phone: 925-282-1778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number308366
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2023-02194
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number308366
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A18705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: