Provider Demographics
NPI:1336808971
Name:MULLEN, ALVIN JAY (LPT)
Entity Type:Individual
Prefix:
First Name:ALVIN JAY
Middle Name:
Last Name:MULLEN
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 W MATHEWS RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9757
Practice Address - Country:US
Practice Address - Phone:209-468-5303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41866167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes167G00000XNursing Service ProvidersLicensed Psychiatric TechnicianGroup - Single Specialty