Healthcare Provider Details

I. General information

NPI: 1124531421
Provider Name (Legal Business Name): JAWAN MULLEN SR. CDAC INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 MOONDANCE CT
HENDERSON NV
89011-4921
US

IV. Provider business mailing address

5940 MOONDANCE CT
HENDERSON NV
89011-4921
US

V. Phone/Fax

Practice location:
  • Phone: 703-269-7616
  • Fax:
Mailing address:
  • Phone: 703-269-7616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number08256-1
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: