Provider Demographics
NPI:1093181489
Name:MULLEN, JEANNE (MT)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:MULLEN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6479
Mailing Address - Country:US
Mailing Address - Phone:715-855-0408
Mailing Address - Fax:715-855-0409
Practice Address - Street 1:517 E CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6479
Practice Address - Country:US
Practice Address - Phone:715-855-0408
Practice Address - Fax:715-855-0409
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist