Provider Demographics
NPI:1194483131
Name:JANKOWSKI, MITCHELL DALE (R1381900320)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DALE
Last Name:JANKOWSKI
Suffix:
Gender:M
Credentials:R1381900320
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1666
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-1666
Mailing Address - Country:US
Mailing Address - Phone:530-626-9240
Mailing Address - Fax:
Practice Address - Street 1:2844 COLOMA ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4406
Practice Address - Country:US
Practice Address - Phone:530-626-9240
Practice Address - Fax:530-642-2064
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)