1558651984 NPI number — JENNIFER LYNN MULLENIX M.S., TLLP

Table of content: JENNIFER LYNN MULLENIX M.S., TLLP (NPI 1558651984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558651984 NPI number — JENNIFER LYNN MULLENIX M.S., TLLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLENIX
Provider First Name:
JENNIFER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., TLLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558651984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7208 CHARTER OAKS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVISON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48423-3310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-241-2928
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6195 MILLER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SWARTZ CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48473-1599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-630-1152
Provider Business Practice Location Address Fax Number:
810-630-9107
Provider Enumeration Date:
04/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  L1995256 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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