Provider Demographics
NPI:1013152362
Name:MCCULLOUGH, JENNIFER DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DAWN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5398 THOMASTON RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-8110
Mailing Address - Country:US
Mailing Address - Phone:478-476-8868
Mailing Address - Fax:
Practice Address - Street 1:5398 THOMASTON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-8110
Practice Address - Country:US
Practice Address - Phone:478-476-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0757582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry