Healthcare Provider Details

I. General information

NPI: 1457005365
Provider Name (Legal Business Name): JESSE BULLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2271 ALPINE BLVD STE A
ALPINE CA
91901-1101
US

IV. Provider business mailing address

13191 KELLAM CT APT 95
SAN DIEGO CA
92130-1279
US

V. Phone/Fax

Practice location:
  • Phone: 619-289-7322
  • Fax:
Mailing address:
  • Phone: 775-901-6190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: