Healthcare Provider Details

I. General information

NPI: 1356963375
Provider Name (Legal Business Name): JESSICA LENA MULLINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W UPPER FERRY RD FL 1
EWING NJ
08628-2725
US

IV. Provider business mailing address

109 W UPPER FERRY RD FL 1
EWING NJ
08628-2725
US

V. Phone/Fax

Practice location:
  • Phone: 423-963-7799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW020745
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC012866
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: