1356788913 NPI number — DR. JESSE REECE MITCHELL BCPPC, DIV, PHD

Table of content: DR. JESSE REECE MITCHELL BCPPC, DIV, PHD (NPI 1356788913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356788913 NPI number — DR. JESSE REECE MITCHELL BCPPC, DIV, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
JESSE
Provider Middle Name:
REECE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
BCPPC, DIV, PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356788913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
149 ACADEMY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMILTON
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35570-3015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-792-1443
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 ACADEMY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMILTON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35570-3015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-792-1443
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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