Healthcare Provider Details

I. General information

NPI: 1063381564
Provider Name (Legal Business Name): JESSICA MULLEN RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2413 ANTIOCH CHURCH RD
MOUNT AIRY GA
30563-1800
US

IV. Provider business mailing address

2413 ANTIOCH CHURCH RD
MOUNT AIRY GA
30563-1800
US

V. Phone/Fax

Practice location:
  • Phone: 478-997-1268
  • Fax:
Mailing address:
  • Phone: 478-997-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number1062091
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: