Healthcare Provider Details

I. General information

NPI: 1982837324
Provider Name (Legal Business Name): JENNY ELIZABETH MULL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 COORS BLVD NW STE C
ALBUQUERQUE NM
87120-1721
US

IV. Provider business mailing address

3320 COORS BLVD NW STE C
ALBUQUERQUE NM
87120-1721
US

V. Phone/Fax

Practice location:
  • Phone: 505-652-4002
  • Fax:
Mailing address:
  • Phone: 505-652-4002
  • Fax: 505-272-1538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08791
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: