Healthcare Provider Details

I. General information

NPI: 1710841473
Provider Name (Legal Business Name): JESSICA MULLIGAN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 W 2ND ST
BLOOMINGTON IN
47403-2209
US

IV. Provider business mailing address

8740 CASH RD
MARTINSVILLE IN
46151-7011
US

V. Phone/Fax

Practice location:
  • Phone: 773-398-3614
  • Fax:
Mailing address:
  • Phone: 773-398-3614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: