Basic Information
| Provider Information | |||||||||
| NPI: | 1700360179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | GIM, 2ND FLOOR | ||||||||
| Address2: | 1008 SOUTH SPRING | ||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142578222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1201 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142578222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.