Provider Demographics
NPI:1891883831
Name:CULLEN, JENIFER M (PHD)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:M
Last Name:CULLEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENIFER
Other - Middle Name:M
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:115 MILL ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1064
Mailing Address - Country:US
Mailing Address - Phone:617-855-2766
Mailing Address - Fax:
Practice Address - Street 1:115 MILL ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1064
Practice Address - Country:US
Practice Address - Phone:617-855-2766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8535103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral