Basic Information
| Provider Information | |||||||||
| NPI: | 1740937671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 552 MOCKINGBIRD CIR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390477363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626142870 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8905 OCEAN SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395644421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282150521 | ||||||||
| FaxNumber: | 2282150619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2022 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT6440 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.