Basic Information
| Provider Information | |||||||||
| NPI: | 1053377671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MULLENAX | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | GAIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4305 UNIVERSITY AVE | ||||||||
| Address2: | STE 150 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195630507 | ||||||||
| FaxNumber: | 6195630015 | ||||||||
| Practice Location | |||||||||
| Address1: | 4058 WILLOWS RD | ||||||||
| Address2: | |||||||||
| City: | ALPINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919011668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194451188 | ||||||||
| FaxNumber: | 6196593140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 01/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G66967 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.