Provider Demographics
NPI:1871747295
Name:BULLOCK, JENNIFER (MED, MLSP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MED, MLSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3303
Mailing Address - Country:US
Mailing Address - Phone:215-957-5073
Mailing Address - Fax:215-887-7369
Practice Address - Street 1:245 S 16TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3303
Practice Address - Country:US
Practice Address - Phone:215-957-5073
Practice Address - Fax:215-887-7369
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004367101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health