MEDICARE: DR. JENNIFER DAWN MCCULLOUGH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	075758	GA

General Provider Information

NPI Number	:	1013152362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER DAWN MCCULLOUGH M.D.

Provider Business Mailing Address
First Line	:	5398 THOMASTON RD
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31220-8110
Country	:	US
Telephone Number	:	478-476-8868
Fax Number	:

Provider Business Practice Location Address
First Line	:	5398 THOMASTON RD
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31220-8110
Country	:	US
Telephone Number	:	478-476-8868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2008
Last Update Date	:	05/10/2017

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