Provider Demographics
NPI:1275201733
Name:MULLEN, JACQUELINE RUTH (MHA,RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RUTH
Last Name:MULLEN
Suffix:
Gender:F
Credentials:MHA,RN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:RUTH
Other - Last Name:ASCENZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2787 HILTONWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027
Mailing Address - Country:US
Mailing Address - Phone:315-420-3659
Mailing Address - Fax:
Practice Address - Street 1:2787 HILTONWOOD ROAD
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027
Practice Address - Country:US
Practice Address - Phone:315-420-3659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY576894-01163WC0400X, 163WC1500X, 163WH0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health