Basic Information
| Provider Information | |||||||||
| NPI: | 1376583989 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73 NEWTON RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | PLAISTOW | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038652424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783887272 | ||||||||
| FaxNumber: | 9783887373 | ||||||||
| Practice Location | |||||||||
| Address1: | 74 GRAY RD | ||||||||
| Address2: | |||||||||
| City: | FALMOUTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041052019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077973006 | ||||||||
| FaxNumber: | 2077973002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 06/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2738 | ME | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 079016 | 01 | ME | ANTHEM ME INDIV # | OTHER |