Provider Demographics
NPI:1891904264
Name:MCCULLUM, JEAN E (MA)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:E
Last Name:MCCULLUM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:E
Other - Last Name:TYLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 COROLLA CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-8172
Mailing Address - Country:US
Mailing Address - Phone:910-347-3857
Mailing Address - Fax:
Practice Address - Street 1:3010 TRENT RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5735
Practice Address - Country:US
Practice Address - Phone:252-636-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6705101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health