Provider Demographics
NPI:1780804070
Name:MULLEN, JACQUELINE ELLEN (MOTR L)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELLEN
Last Name:MULLEN
Suffix:
Gender:F
Credentials:MOTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5334 OLYMPIC DR NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1722
Mailing Address - Country:US
Mailing Address - Phone:253-853-5155
Mailing Address - Fax:253-853-5150
Practice Address - Street 1:5334 OLYMPIC DR NW
Practice Address - Street 2:SUITE 101
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1722
Practice Address - Country:US
Practice Address - Phone:253-853-5155
Practice Address - Fax:253-853-5150
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00004417174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist