NPI Code Detail JSON Logo

1306630736 NPI number — JACOB ALLEN MITCHELL CCP

NPI Number: 1306630736
Health Care Provider/Practitioner: JACOB ALLEN MITCHELL CCP

Information about “1306630736” NPI (JACOB ALLEN MITCHELL CCP) exists in 1306630736 in HTML format HTML  |  1306630736 in plain Text format TXT  |  1306630736 in PDF (Portable Document Format) PDF  |  1306630736 in an XML format XML  formats.

NPI Number : 1306630736 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1306630736",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "MITCHELL",
    "FirstName": "JACOB",
    "MiddleName": "ALLEN",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "CCP",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "4084 CRYSTAL DAWN LN UNIT 201",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "SAN DIEGO",
    "MailingAddressStateName": "CA",
    "MailingAddressPostalCode": "92122-5846",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "608-697-9321",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "9888 GENESEE AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "LA JOLLA",
    "PracticeLocationAddressStateName": "CA",
    "PracticeLocationAddressPostalCode": "92037-1205",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "858-834-1798",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "04/09/2025",
    "LastUpdateDate": "04/09/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "242T00000X",
        "TaxonomyName": "Perfusionist",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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