Healthcare Provider Details

I. General information

NPI: 1558930032
Provider Name (Legal Business Name): MRS. JENNIFER LYNN MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 COURT DR # B
GASTONIA NC
28054-1478
US

IV. Provider business mailing address

407 W VIRGINIA AVE
BESSEMER CITY NC
28016-2216
US

V. Phone/Fax

Practice location:
  • Phone: 704-000-0000
  • Fax:
Mailing address:
  • Phone: 704-579-2297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: