Healthcare Provider Details

I. General information

NPI: 1982236741
Provider Name (Legal Business Name): JOLIN MITCHEL LPC, CRC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 S YELLOWSTONE DR STE 219
MADISON WI
53719-1061
US

IV. Provider business mailing address

421 LUSTER AVE
MADISON WI
53704-1515
US

V. Phone/Fax

Practice location:
  • Phone: 608-251-4164
  • Fax:
Mailing address:
  • Phone: 608-251-4164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7104
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number111708
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7104
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: