MEDICARE: JESSICA LENA MULLINS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CW020745	PA
2	1041C0700X	Clinical Social Worker	C012866	NC

General Provider Information

NPI Number	:	1356963375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LENA MULLINS LCSW

Provider Business Mailing Address
First Line	:	109 W UPPER FERRY RD FL 1
Second Line	:
City	:	EWING
State	:	NJ
Zip	:	08628-2725
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 W UPPER FERRY RD FL 1
Second Line	:
City	:	EWING
State	:	NJ
Zip	:	08628-2725
Country	:	US
Telephone Number	:	423-963-7799
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2020
Last Update Date	:	05/13/2020

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