Purpose Mild cognitive impairment (MCI) is a well‐recognized risk state for Alzheimer's disease and other dementias. MCI is rapidly increasing among older adults in general and has not yet been examined in older adults within the Appalachian region. Our objective was to compare MCI symptom severity among older rural and urban Appalachian adults with MCI at an initial neuropsychological testing visit. Methods A cross‐sectional, descriptive study of older Appalachian adults with MCI was conducted using data from the National Alzheimer's Coordinating Center Uniform Data Set. Symptom severity was conceptualized as neuropsychological composite scores across 4 cognitive domains and Clinical Dementia Rating‐Sum of Boxes (CDR‐SOB) score. For group comparisons, MANCOVA was used for cognitive domains and ANCOVA for CDR‐SOB. Results The sample (N = 289) was about half male (54.3%), predominantly white (91.7%), and living with others (83.5%), with a mean (±SD) 74.6 ± 6.2 years of age and 15.4 ± 3.0 years of education. Rural and urban groups differed significantly in years since onset of cognitive symptoms (2.98 ± 1.91 in rural and 3.89 ± 2.70 in urban adults, t[260] = –2.23, P = .03), but they did not differ across sociodemographic features or comorbid conditions. Rural and urban participants were similar across the 4 cognitive domains and CDR‐SOB (P ≥ .05). Discussion No differences were found between rural and urban Appalachian residents on MCI symptom severity. However, urban residents reported a longer time lapse from symptom identification to diagnosis than their rural counterparts. Future studies using more representative population samples of Appalachian and non‐Appalachian adults will provide an important next step to identifying disparate cognitive health outcomes in this traditionally underserved region.