Provider Demographics
NPI:1457631780
Name:MULLINS, JENNY FAYE (DO)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:FAYE
Last Name:MULLINS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-1973
Mailing Address - Country:US
Mailing Address - Phone:606-487-9505
Mailing Address - Fax:606-436-0071
Practice Address - Street 1:279 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1973
Practice Address - Country:US
Practice Address - Phone:606-487-9505
Practice Address - Fax:606-436-0071
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03746207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY181853OtherFQHC BREATHITT
KY7100323170Medicaid
KY181848OtherFQHC LEE COUNTY
KY7100323170Medicaid