Healthcare Provider Details

I. General information

NPI: 1194410316
Provider Name (Legal Business Name): JACOB CONNARD MULLINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 E COURT AVE
SELMER TN
38375-2304
US

IV. Provider business mailing address

257 BANCORP SOUTH PKWY
JACKSON TN
38305-7582
US

V. Phone/Fax

Practice location:
  • Phone: 731-645-7932
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number76924
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: