Basic Information
| Provider Information | |||||||||
| NPI: | 1386021814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1105 E FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925434512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514392939 | ||||||||
| FaxNumber: | 9514392940 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 E FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925434512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514392939 | ||||||||
| FaxNumber: | 9514392940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2015 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF76168 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 114769 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.