Provider Demographics
NPI:1356800742
Name:MITCHELL, JACOB ANDERSON
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDERSON
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 1:100 GENEVIEVE CT STE A
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4868
Mailing Address - Country:US
Mailing Address - Phone:770-486-1818
Mailing Address - Fax:770-486-7303
Practice Address - Street 1:100 GENEVIEVE CT STE A
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4868
Practice Address - Country:US
Practice Address - Phone:770-486-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11837364-1205207Q00000X
390200000X
GA91704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program