Healthcare Provider Details

I. General information

NPI: 1477830495
Provider Name (Legal Business Name): JENNIFER MARISA MITCHELL M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 STANIFORD ST FL 2 BOSTON EMERGENCY SERVIES TEAM
BOSTON MA
02114-2503
US

IV. Provider business mailing address

33 I ST APT 1
SOUTH BOSTON MA
02127-1429
US

V. Phone/Fax

Practice location:
  • Phone: 800-981-4353
  • Fax:
Mailing address:
  • Phone: 508-935-7515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number438105
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: