Provider Demographics
NPI:1710282371
Name:TULLIUS, JESSICA LEIGH (LAC, MACOM)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEIGH
Last Name:TULLIUS
Suffix:
Gender:F
Credentials:LAC, MACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 N MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2365
Mailing Address - Country:US
Mailing Address - Phone:970-641-6095
Mailing Address - Fax:
Practice Address - Street 1:144 N MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2365
Practice Address - Country:US
Practice Address - Phone:970-641-6095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1233171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist