Provider Demographics
NPI:1447050950
Name:PULLIAM, JORDAN ZACHARY (BS)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ZACHARY
Last Name:PULLIAM
Suffix:
Gender:
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10328 TURKEY OAK DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-5840
Mailing Address - Country:US
Mailing Address - Phone:813-720-0581
Mailing Address - Fax:
Practice Address - Street 1:40347 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-4840
Practice Address - Country:US
Practice Address - Phone:727-330-8932
Practice Address - Fax:727-772-8212
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FLRBT-25-419376106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician