Provider Demographics
NPI:1588892483
Name:MULLEN, JENNIFER LATRISE (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LATRISE
Last Name:MULLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:660 BEAVER CREEK CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1745
Mailing Address - Country:US
Mailing Address - Phone:419-891-6221
Mailing Address - Fax:419-893-3394
Practice Address - Street 1:660 BEAVER CREEK CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1745
Practice Address - Country:US
Practice Address - Phone:419-891-6221
Practice Address - Fax:419-893-3394
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34010645208000000X
TXV4441208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics