Healthcare Provider Details

I. General information

NPI: 1710431671
Provider Name (Legal Business Name): JON MITCHELL LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1353 W MAIN ST
LEXINGTON KY
40508-2065
US

IV. Provider business mailing address

3175 CUSTER DR STE 303
LEXINGTON KY
40517-4023
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 859-312-4484
  • Fax: 502-631-9660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number243809
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: