Healthcare Provider Details

I. General information

NPI: 1528515566
Provider Name (Legal Business Name): JEANNE MULLALLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 4TH AVE SW ROOM 238
ALBANY OR
97321-2804
US

IV. Provider business mailing address

PO BOX 100
ALBANY OR
97321-0031
US

V. Phone/Fax

Practice location:
  • Phone: 541-967-3819
  • Fax: 541-967-7259
Mailing address:
  • Phone: 541-967-3819
  • Fax: 541-967-7259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL2225
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2225
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: