MEDICARE: JACOB MULLINS LCPC

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	101YP2500X	Professional Counselor	180016971	IL

General Provider Information

NPI Number	:	1841080173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB MULLINS LCPC

Provider Business Mailing Address
First Line	:	5600 N RIDGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-0097
Country	:	US
Telephone Number	:	630-414-7506
Fax Number	:

Provider Business Practice Location Address
First Line	:	5600 N RIDGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-0097
Country	:	US
Telephone Number	:	630-414-7507
Fax Number	:

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

Provider Enumeration Date	:	05/09/2025
Last Update Date	:	05/09/2025

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