=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689792798
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON CHRISTOPHER MITCHELL MSED, ATC, V, ATL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 04/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | OLD DOMINION UNIVERSITY ATHLETIC ADMINISTRATION BUILDING #1113C
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23529-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-683-6462
-----------------------------------------------------
Fax | 757-683-5445
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8908 SEMMES AVE
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23503-4828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-382-8214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT3766
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------