Healthcare Provider Details

I. General information

NPI: 1194956243
Provider Name (Legal Business Name): JAMIE L BULLOCK P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 12/04/2022
Certification Date: 12/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 23RD ST NW
WASHINGTON DC
20037-2342
US

IV. Provider business mailing address

20010 CENTURY BLVD. SUITE 200
GERMANTOWN MD
20874-1106
US

V. Phone/Fax

Practice location:
  • Phone: 202-715-4000
  • Fax: 202-715-4015
Mailing address:
  • Phone: 240-686-2300
  • Fax: 240-686-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003049
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: