Healthcare Provider Details

I. General information

NPI: 1083912307
Provider Name (Legal Business Name): JENNIFER MITCHELL PH.D, BCBA-D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5242 S 4820 W
KEARNS UT
84118-6422
US

IV. Provider business mailing address

350 S 400 E
SALT LAKE CITY UT
84111-2908
US

V. Phone/Fax

Practice location:
  • Phone: 801-966-4251
  • Fax: 801-966-4289
Mailing address:
  • Phone: 801-582-5534
  • Fax: 801-582-5540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number8431995-2501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number8431995-2506
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: