=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215438098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LEE MITCHELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2018
-----------------------------------------------------
Last Update Date | 10/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3965 S MENDENHALL RD STE 20
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38115-5954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-620-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 526 COUNTY ROAD 102
-----------------------------------------------------
City | BRECKENRIDGE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76424-8301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-559-0797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2018008064
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 12070
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------