Provider Demographics
NPI:1861363442
Name:MULVEY, JAKE KENJI
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:KENJI
Last Name:MULVEY
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 1:110 NORFOK AVE
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907
Mailing Address - Country:US
Mailing Address - Phone:781-715-5729
Mailing Address - Fax:
Practice Address - Street 1:800 W CUMMINGS PARK STE 3400
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6551
Practice Address - Country:US
Practice Address - Phone:781-715-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program