Healthcare Provider Details

I. General information

NPI: 1841554615
Provider Name (Legal Business Name): JENNIFER ELIZABETH MULLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11476 S APOPKA VINELAND RD SUITE 118
ORLANDO FL
32836-7006
US

IV. Provider business mailing address

175 MIDDLE ST SUITE 1201
LAKE MARY FL
32746-3625
US

V. Phone/Fax

Practice location:
  • Phone: 407-955-4001
  • Fax: 407-745-0738
Mailing address:
  • Phone: 866-610-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: