MEDICARE: JERICHA MITCHEM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-24-71781	GA
2	103K00000X	Behavior Analyst	4016	NC

General Provider Information

NPI Number	:	1275208860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERICHA MITCHEM

Provider Business Mailing Address
First Line	:	209 7TH ST FL 3
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30901-1486
Country	:	US
Telephone Number	:	706-842-5330
Fax Number	:	706-842-5340

Provider Business Practice Location Address
First Line	:	8415 PINEVILLE MATTHEWS RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4704
Country	:	US
Telephone Number	:	706-842-5330
Fax Number	:	706-842-5340

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2021
Last Update Date	:	06/10/2026

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Directions to “ JERICHA MITCHEM ” Practice Location

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