Provider Demographics
NPI:1801518451
Name:PULLIAM, JAE
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:PULLIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1139
Mailing Address - Country:US
Mailing Address - Phone:781-691-7060
Mailing Address - Fax:
Practice Address - Street 1:100 WILLOW ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1139
Practice Address - Country:US
Practice Address - Phone:781-691-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA171M00000XMedicaid