Healthcare Provider Details

I. General information

NPI: 1376331132
Provider Name (Legal Business Name): JEREZ MITCHELL PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

8561 SENTRY CIR
NORTH CHARLESTON SC
29420-8354
US

V. Phone/Fax

Practice location:
  • Phone: 843-577-5011
  • Fax:
Mailing address:
  • Phone: 817-308-7834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1918
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: