Provider Demographics
NPI:1609262278
Name:BULLOCK, JESSICA ELAINE (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:BULLOCK
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:BULLOCK
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33 LONO AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-1634
Mailing Address - Country:US
Mailing Address - Phone:808-500-3439
Mailing Address - Fax:
Practice Address - Street 1:33 LONO AVE STE 250
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1634
Practice Address - Country:US
Practice Address - Phone:808-500-3439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19423363L00000X
HI2240363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3164Medicaid
HI812778Medicaid