Healthcare Provider Details

I. General information

NPI: 1235569369
Provider Name (Legal Business Name): JESSICA CULLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA BOX

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N RANDALL AVE
JANESVILLE WI
53545-1958
US

IV. Provider business mailing address

74 ECLIPSE CTR
BELOIT WI
53511-3550
US

V. Phone/Fax

Practice location:
  • Phone: 608-752-7660
  • Fax:
Mailing address:
  • Phone: 608-361-0311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5989-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: