Provider Demographics
NPI:1063190734
Name:MITCHELL, JACOB WAGNER
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:WAGNER
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-4229
Mailing Address - Country:US
Mailing Address - Phone:870-424-4670
Mailing Address - Fax:
Practice Address - Street 1:2338 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-6184
Practice Address - Country:US
Practice Address - Phone:870-424-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist