Provider Demographics
NPI:1215438098
Name:MITCHELL, JENNIFER LEE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 COUNTY ROAD 102
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:76424-8301
Mailing Address - Country:US
Mailing Address - Phone:254-559-0797
Mailing Address - Fax:
Practice Address - Street 1:3965 S MENDENHALL RD STE 20
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-5954
Practice Address - Country:US
Practice Address - Phone:901-620-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018008064225100000X
TN12070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist