Basic Information
| Provider Information | |||||||||
| NPI: | 1003153743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MITCHELL | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | TURNER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 353 NEW SHACKLE ISLAND RD STE 122B | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370752329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158242014 | ||||||||
| FaxNumber: | 6158242081 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 NEW SHACKLE ISLAND RD | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158243737 | ||||||||
| FaxNumber: | 8886876133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2013 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2243 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1531250 | 05 | TN | MEDICAID | 7100259470 | 05 | KY | MEDICAID |