Healthcare Provider Details

I. General information

NPI: 1225478431
Provider Name (Legal Business Name): JORDAN BULLOCK MHPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BOB COURTWAY DR SUITE 9
CONWAY AR
72032-4766
US

IV. Provider business mailing address

1100 BOB COURTWAY DR SUITE 9
CONWAY AR
72032-4766
US

V. Phone/Fax

Practice location:
  • Phone: 501-328-5525
  • Fax: 501-328-5342
Mailing address:
  • Phone: 501-328-5525
  • Fax: 501-328-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: