Provider Demographics
NPI:1821488073
Name:CULLEN, JESSICA LEE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:CULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2579 E 17TH ST STE 28
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3515
Mailing Address - Country:US
Mailing Address - Phone:347-708-0777
Mailing Address - Fax:347-464-0013
Practice Address - Street 1:2579 E 17TH ST STE 28
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3515
Practice Address - Country:US
Practice Address - Phone:347-708-0777
Practice Address - Fax:347-464-0013
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid