Healthcare Provider Details

I. General information

NPI: 1588892483
Provider Name (Legal Business Name): JENNIFER LATRISE MULLEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 BEAVER CREEK CIR SUITE 100
MAUMEE OH
43537-1745
US

IV. Provider business mailing address

660 BEAVER CREEK CIR SUITE 100
MAUMEE OH
43537-1745
US

V. Phone/Fax

Practice location:
  • Phone: 419-891-6221
  • Fax: 419-893-3394
Mailing address:
  • Phone: 419-891-6221
  • Fax: 419-893-3394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34010645
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberV4441
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: