Provider Demographics
NPI:1548828684
Name:NELSON-MITCHELL, JESSICA ROBIN (LADC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROBIN
Last Name:NELSON-MITCHELL
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 ASHBROOK PATH
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-4820
Mailing Address - Country:US
Mailing Address - Phone:952-322-0579
Mailing Address - Fax:
Practice Address - Street 1:217 PLUM ST
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2351
Practice Address - Country:US
Practice Address - Phone:651-447-8678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303791101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)