Healthcare Provider Details

I. General information

NPI: 1750823530
Provider Name (Legal Business Name): JESSICA BULLOCK PMHNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA KATHERINE - MILNES BULLOCK

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 UNION AVE
SAN JOSE CA
95124-5156
US

IV. Provider business mailing address

4831 RIVERVALE DR
SOQUEL CA
95073-9727
US

V. Phone/Fax

Practice location:
  • Phone: 800-913-2615
  • Fax:
Mailing address:
  • Phone: 503-884-6518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95146518
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95019999
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201242077RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: