Provider Demographics
NPI:1306630736
Name:MITCHELL, JACOB ALLEN (CCP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ALLEN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4084 CRYSTAL DAWN LN UNIT 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5846
Mailing Address - Country:US
Mailing Address - Phone:608-697-9321
Mailing Address - Fax:
Practice Address - Street 1:9888 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-834-1798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist