Provider Demographics
NPI:1366159949
Name:MCCULLOUGH, JESSICA (LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 WHITE DOVE CV
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-4915
Mailing Address - Country:US
Mailing Address - Phone:512-988-6503
Mailing Address - Fax:
Practice Address - Street 1:3109 KENAI DR
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2536
Practice Address - Country:US
Practice Address - Phone:512-988-6503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC02031171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAC02031OtherTEXAS MEDICAL BOARD
845934OtherNCCAOM