MEDICARE: JACLYN TULLY M.A., LMFT

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	106H00000X	Marriage & Family Therapist	51810	CA

General Provider Information

NPI Number	:	1992936231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN TULLY M.A., LMFT

Provider Business Mailing Address
First Line	:	864 S ROBERTSON BLVD
Second Line	:	SUITE 202
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1605
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	864 S ROBERTSON BLVD
Second Line	:	SUITE 202
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1605
Country	:	US
Telephone Number	:	812-589-9070
Fax Number	:

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

Provider Enumeration Date	:	08/04/2009
Last Update Date	:	03/25/2013

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