Provider Demographics
NPI:1144468471
Name:MULLEN, JODI LEE
Entity type:Individual
Prefix:MRS
First Name:JODI
Middle Name:LEE
Last Name:MULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7075 WORLINE RD
Mailing Address - Street 2:
Mailing Address - City:BOW
Mailing Address - State:WA
Mailing Address - Zip Code:98232-9640
Mailing Address - Country:US
Mailing Address - Phone:360-202-3505
Mailing Address - Fax:360-424-6009
Practice Address - Street 1:2118 RIVERSIDE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5454
Practice Address - Country:US
Practice Address - Phone:360-202-3505
Practice Address - Fax:360-424-6009
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022122174400000X
WA0206084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist