Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1083283444 |
---|---|
Provider Name | Jake Mitchell |
First Address | Grosse Pointe Woods, MI 48236-2893 |
Second Address | Grosse Pointe Woods, MI 48236-2893 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2021 |
Last Update Date | 21/06/2021 |