Basic Information
| Provider Information | |||||||||
| NPI: | 1205067493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JESUS | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCDC-III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 521 BEALL AVE | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446913589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302627836 | ||||||||
| FaxNumber: | 3302622867 | ||||||||
| Practice Location | |||||||||
| Address1: | 521 BEALL AVE | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446913589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302627836 | ||||||||
| FaxNumber: | 3302622867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2009 | ||||||||
| LastUpdateDate: | 08/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 081228 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.